Survival of African American and non‐Hispanic white men with prostate cancer in an equal‐access health care system

Abstract

Background African American (AA) men in the general US population are more than twice as likely to die of prostate cancer (PC) compared with non‐Hispanic white (NHW) men. The authors hypothesized that receiving care through the Veterans Affairs (VA) health system, an equal‐access medical system, would attenuate this disparity. Methods A longitudinal, centralized database of >20 million veterans was used to assemble a cohort of 60,035 men (18,201 AA men [30.3%] and 41,834 NHW men [69.7%]) who were diagnosed with PC between 2000 and 2015. Results AA men were more likely to live in regions with a lower median income ($40,871 for AA men vs $48,125 for NHW men; P < .001) and lower high school graduation rates (83% for AA men vs 88% for NHW men; P < .001). At the time of diagnosis, AA men were younger (median age, 63.0 years vs 66.0 years; P < .001) and had a higher prostate‐specific antigen level (median, 6.7 ng/mL vs 6.2 ng/mL; P < .001), but were less likely to have Gleason score 8 to 10 disease (18.8% among AA men vs 19.7% among NHW men; P < .001), a clinical T classification ≥3 (2.2% vs 2.9%; P < .001), or distant metastatic disease (2.7% vs 3.1%; P = 0.01). The 10‐year PC‐specific mortality rate was slightly lower for AA men (4.4% vs 5.1%; P = .005), which was confirmed in multivariable competing‐risk analysis (subdistribution hazard ratio, 0.85; 95% CI, 0.78‐0.93; P < .001). Conclusions AA men diagnosed with PC in the VA health system do not appear to present with more advanced disease or experience worse outcomes compared with NHW men, in contrast to national trends, suggesting that access to care is an important determinant of racial equity.

Access and socioeconomic status play an important role in outcomes for African American patients with prostate cancer

“…It is gratifying that this work by Riviere et al 1 validates work by our group and others that over a decade ago demonstrated that socioeconomic status and access to health care explained the differences in lower treatment rates and poorer outcomes noted among AA men with PCa 2‐4 …”

“…We would like to congratulate Riviere et al on their study of longitudinal data from 60,035 men who were diagnosed with prostate cancer (PCa) between 2000 and 2015, 1 which highlighted that access to care is an important determinant of racial inequity. In their study, African American (AA) men who were diagnosed with PCa in the Veterans Affairs health system did not appear to present with more advanced disease or to experience worse outcomes compared with non‐Hispanic white men.…”

“…Although PCa diagnosed in AA men may be biologically different (which perhaps is reflected in the higher incidence of PCa noted among AA men 3 ), the study by Riviere et al 1 demonstrated that response to treatment and outcomes are no different between racial groups. Initiatives to enhance AA men's access to care and early diagnosis may not only overcome racial disparities in outcomes, but also shed light on the influence of tumor biology in the incidence of PCa among AA men.…”

“…It also is timely that Riviere et al concluded that “it is plausible that equal‐access health care coverage plays an important role in outcomes for these [African American] patients.” 1 As the Veterans Affairs model and Medicaid are a testament to, access is an entirely surmountable risk.…”

Reply to Equal access to health care reduces racial disparities in prostate cancer outcomes and Access and socioeconomic status play an important role in outcomes for African American patients with prostate cancer

“…We would like to thank Lundon et al and Hoge et al for their insightful letters and research contributions to this field 1,2 . Our work 3 has built on a large body of literature suggesting that socioeconomic factors and access to medical care are the primary drivers of poorer outcomes for African American men with prostate cancer. Our study added to this work by pointing toward a solution that is working in practice throughout the United States, suggesting that poorer outcomes for African American men with prostate cancer do not need to be a foregone conclusion.…”