Introduction:

In the United States, Black men with prostate cancer are less likely to receive definitive treatment and have worse survival compared to White men. Some research suggests that racial differences in prostate cancer care (PCa) and outcomes may be attributable to the site of care. Systemic racism and historical policies such as “redlining” have racially segregated neighborhoods resulting in a differential allocation of health care and social services, where Black men are more likely to be treated at resource-deprived settings. Therefore, we sought to examine the receipt of guideline-concordant definitive treatment, time to treatment initiation (TTI), and survival for men with PCa at hospital systems serving health disparity populations (HSDPs).

Methods:

We conducted a retrospective analysis of the National Cancer Database (2004-2016) in a cohort of Black and White men with intermediate-risk or high-risk prostate cancer eligible for definitive treatment based on the National Comprehensive Cancer Network guidelines. The primary outcomes were receipt of definitive treatment as well as TTI within 90 days. The secondary outcome was survival factored by facility status. We defined HSDPs as minority-serving hospitals (MSHs) – facilities with the highest decile of proportion of non-Hispanic Black or Hispanic cancer patients–and/or high-burden safety-net hospitals (SNHs) – highest quartile of facilities serving uninsured cancer patients or patients covered by Medicaid. We used mixed-effect models with facility-level random intercept adjusting for patient demographics, comorbidities, socioeconomic status, and facility caseload to compare the outcomes of HSDP and non-HSDP. For survival analysis, we used adjusted mixed-effect survival models with Weibull distribution, and sensitivity analysis was conducted among men who received definitive treatment.

Results:

The proportion of care received at MSHs, high-burden SNHs, and HSDPs was 7.4%, 19.1%, and 21.5%, respectively. Men who received care at HSDPs were more likely to be non-Hispanic Black (26.4% vs. 11.3%), uninsured (3.8% vs. 0.9%) or with Medicaid coverage (3.8% vs. 0.9%), have an income <$38,000 (6.1% vs. 1.5%), and have less than a high school degree (54.6% vs. 34.7%) - Table 1. In adjusted analysis, treatment at HSDPs was associated with lower odds of receipt of indicated treatment (OR, 0.64; 95%CI 0.57 to 0.71; p=0.001) and lower odds for TTI within 90 days of diagnosis (0.80; 95%CI 0.74 to 0.86; p=0.001). Moreover, care at HSDPs was associated with worse survival (HR 1.05; 95%CI 1.02 to 1.09; p=0.03) - Figure 1, but no difference was found among men who received indicated therapy at HSDPs vs. non-HSDPs (1.03; 95%CI 0.99 to 1.07; p=0.1).

Conclusion:

Among Black and White men with prostate cancer, definitive treatment, TTI within 90 days as well as survival were inferior at HSDPs. No difference in survival was found between HSDPs vs. non-HSDPs among men who received indicated treatment. Thus, future quantitative and qualitative research is needed to answer how socioeconomic barriers such as systemic racism and underinsurance contribute to the facility-level gap in access to definitive treatment and overall survival between HSDPs and non-HSDPs.

Funding: N/A