Introduction:

There are marked disparities in prostate cancer mortality between ethnic/racial groups. In recent years, there has been growing research into the impact of structural racism and healthcare outcomes. We sought to evaluate associations between prostate cancer mortality and indices of structural racism, by county and state in the US.  

Methods:

This was a serial cross-sectional study using US national level data from CDC Wonder between the years 2018-2020. We calculated age-adjusted mortality rate (reported as deaths per 100,000 individuals) for prostate cancer by county (when available) and state. We used the structural racism effect index (SREI)—a validated, county-level composite score of structural racism focused on nine domains: built environment, criminal justice, education, employment, housing, income and poverty, social cohesion, transportation, and wealth. Higher index scores indicate higher levels of structural racism. Poisson regression with robust variance estimation was used to generate risk estimates for the association between both state and county-level mean SREI and prostate cancer mortality.

Results:

The age adjusted mortality rate for prostate cancer was highest in Mississippi (24.2) and lowest in Hawaii (15.2). The mean SREI was highest in Mississippi, Louisiana and Alabama, and was lowest in Massachusetts, New Hampshire and Hawaii. Prostate cancer mortality was most concentrated in counties with higher SREI, which were more commonly located within the Southeast. There was a significant positive association between increasing SREI and prostate cancer mortality at the county level (p <0.001); this association was independent of the state of that county.

Conclusion:

In the US, areas with higher mean SREI are associated with higher rates of prostate cancer mortality. Given that an increased proportion of Black residents live in regions with higher SREIs, Black Americans may be disproportionately affected by structural racism in prostate cancer outcomes. Dedicated attention is needed to address the impact of structural racism on inequities in prostate cancer care in the US. Specifically, counties and states with higher mean SREI may benefit most from focused allocation of resources and/or policy change to this end. 

Funding: n/a