Secondary care gap tied to prostate cancer deaths

An observational study of more than 83,000 older U.S. men with localized prostate cancer found that Black and white patients were equally likely to receive secondary treatment after initial therapy, whether their first treatment was surgery or radiation.

However, among patients who did not receive secondary treatment, Black men had up to two times higher risk of dying from prostate cancer than white men.

The findings were published July 21 in JAMA Network Open.

“To our knowledge, this study is the first to examine how receiving secondary treatment may contribute to racial disparities in mortality among prostate cancer patients,” said first author Dr. Jessica Acolin, who pursued the research during postdoctoral training in psychiatry and behavioral sciences at the University of Washington School of Medicine. She is now an affiliate assistant professor in health systems and population health at the UW School of Public Health. 

Black men are more than twice as likely as white men to die from prostate cancer in the United States. Understanding where disparities emerge after diagnosis and initial treatment could help identify opportunities to improve long-term outcomes and reduce inequities in cancer care.

The study included 83,156 Medicare beneficiaries age 66 and older diagnosed with localized prostate cancer between 2004 and 2017. It utilized the Surveillance, Epidemiology and End Results (SEER)-Medicare-linked database, which combines clinical information from population-based cancer registries with claims information from the Medicare program.

The study population was divided into two groups based on their primary treatment type: surgical removal of the prostate or radiation therapy. This approach minimized underlying differences in cancer severity and additional health issues, because patients who received similar treatments had similar characteristics. 

Secondary treatment is offered if the cancer returns after initial treatment. Depending on first steps, secondary treatment could include radiation, surgery, androgen-deprivation therapy, cryotherapy, chemotherapy or high-intensity focused ultrasound.

About 19% of surgery patients and 28% of radiation patients received secondary treatment, with no significant racial differences seen in whether they received that care and survival after receiving secondary treatment.

But among patients who didn’t receive secondary treatment, 1.85% of Black patients died from prostate cancer, a rate more than twice that of white patients.

In the group that had surgery as first treatment, 19% of Black patients who did not receive secondary treatment died, compared with 13% of white patients. In the radiation cohort, 37% of Black patients who did not get secondary treatment died versus 30% of white patients.

Because the cancer characteristics — and consequently, downstream outcomes — were expected to be similar between Black and white patients at the time of primary treatment, these findings raise concerns of disparities in who receives potentially beneficial secondary care.

“Our guess would be that there's less follow-up surveillance among Black patients, because you need to be going in regularly to get the tests,” Acolin said. “If they're not getting the tests as frequently, any recurrence might be caught later, which means that it might be past the point where additional treatment would be recommended because the cancer advanced too far.”

The findings suggest that the overall rate of treatment alone does not explain persistent racial disparities in prostate cancer deaths. Instead, the researchers say the unequal outcomes point to possible differences in access to care, quality of follow-up, timing of treatment, monitoring after initial therapy, or other social and structural factors. Additional research is needed to determine the specific causes.

Acolin said the findings show prostate cancer patients must remain vigilant: “The takeaway, especially for Black men, is that the prostate cancer treatment story doesn't end after first treatment. There are still lots of things that can happen afterwards, like quality of care and continued follow-up, that matter for long-term survival.” 

Alcolin’s research was overseen by co-author Dr. Ruth Etzioni, an affiliate professor of biostatistics, UW School of Public Health, and a biostatistician at Fred Hutch Cancer Center. Senior author Dr. Yaw Nyame is an assistant professor of urology at the UW School of Medicine and a Fred Hutch Cancer Center faculty member.

The research was funded by grants from the Department of Defense (CDMRP W81XWH211053), National Cancer Institute (P50 CA097186-17 and U01 CA253915), the Andy Hill CARE Fund (FY23-POP-02) and National Institute on Alcohol Abuse and Alcoholism (T32AA007455).

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