Leveraging Health Policy to Address Disparities in Prostate Cancer: From the Staff Meeting to the State House
By: Mayra I. Lucas, BS, MPH; Alexander P. Cole, MD | Posted on: 01 Sep 2022
It is projected that racial and ethnic minority individuals will make up over half of the United States population by 2045, yet racial and ethnic health disparities in cancer diagnosis and treatment persist. As prostate cancer care continues to advance, it is crucial to ensure that it does so in a way that ensures equity and excellence for all patients.
The reasons for worse prostate cancer outcomes for some racial and ethnic minority groups are complex and include structural racism as manifested by geographic, community, and hospital factors as well as patient-level factors (eg culture, values, health literacy, and health insurance coverage). These may influence and reinforce discriminatory beliefs, values, and distribution of resources, which may further entrench unequal care.
Work by our team and others has yielded insights into some factors which underlie racial and ethnic disparities in prostate cancer outcomes. Differences in treatment and access to care are one major consideration. Because prostate cancer is one of the most “insurance sensitive” of the big 6 cancer killers, differences in insurance coverage exert a particularly great burden for Black men at risk for prostate cancer.1 A retrospective analysis by Krimphove et al reported that access-related variables account for 84.7% of the excess risk of death for Black men with potentially lethal prostate cancer.2
There are clues to how these issues can be addressed. A recent publication by Alkhatib et al found that racial differences in prostate cancer screening behaviors are mitigated among veterans, who have access to standardized, low-cost health coverage and an integrated national health system.3 In the Krimphove paper, weighted cohorts simulating equivalent access to treatment revealed better overall survival in Black men.2 This is not just theoretical: in Massachusetts, which has had near universal insurance coverage since 2006 with advanced health infrastructure in cities with large minority populations such as Boston, Black men again experience cancer-specific survival which exceeds that of White men.4
These results and others suggest that worse outcomes among Black men are not a foregone conclusion. When Black men are well-insured, screened, and receive prompt diagnosis and access to treatment within high-quality health systems, equitable prostate cancer outcomes follow.
Pilot programs are attempting to achieve equity in access to care. Here in Boston, the United Against Racism program of Mass General Brigham has supported our work in developing a Prostate Cancer Outreach Clinic to improve access to prostate cancer screening, diagnosis, and treatment in underserved communities in Massachusetts. The Prostate Cancer Outreach Clinic will start with community outreach and education events to connect patients in underserved areas in Boston to cancer care, and will later involve establishing a permanent clinic in the area.
While pathways and policies to improve access for underserved minority patients can address part of the problem, they do not necessarily address the more pernicious problem of discriminatory beliefs, values, and implicit biases within the physician workforce. As urologists, are there policies we can support to address this problem?
We know that more diverse teams make fairer decisions. In a study of jury trials from the state of Florida, all-White juries were 16% more likely to convict Black defendants. When juries included even a single Black member, this large difference disappeared and conviction rates were identical. While we believe that the medical community can do far better than adding just a single minority member to our teams, this finding suggests the outsized benefits that can result from even small efforts to create more diverse teams.
Doctors aren’t deciding court cases, but we do make life-changing decisions daily. Shouldn’t our teams also benefit from diversity in these ways? As we look forward to medical student clerkships, fellowships, and residency interviews, local and institutional policies to support diversity are an achievable step that may make a large difference.
Recent work by Loeb et al found that Black patients are more likely to trust prostate cancer information from a Black physician.5 Previous health care studies also demonstrate that diverse medical teams enhance patient care, outcomes, and financial performance. The same studies reported increased innovation, team communication, and risk assessment with increased diversity.6
Despite the clear benefits of diverse teams, only 2.1% of practicing urologists in the United States are Black, and only 3.8% are Hispanic or Latinx.7 These proportions have not changed since 2015 despite calls to increase diversity in the workforce by the American Urological Association.7 This results from multiple factors along multiple points in educational training that disproportionately affect underrepresented minorities in medicine (URiM). For example, Black and Latinx students are less likely to learn about urology before their clinical year in medical school.8 Late exposure to the field leads to decreased opportunities for mentorship, research, and clinical experiences, and applicant counseling, which may result in lower match rates and representation at the residency, fellowship, and faculty levels.
Simple steps may improve minority recruitment. The Association of American Medical Colleges encourages residency programs to embrace a more holistic review of residency applications that considers experiences and attributes in addition to academic performance.9 Residency programs can also increase the number of URiM faculty and residents involved in screening applications. A cross-sectional survey distributed to urology programs nationwide revealed that few involve URiM faculty in screening applications, and only 7% involve URiM residents.10
While the issues underlying unequal prostate cancer outcomes are complex and multifactorial, work by our team suggests that policies focused on improving access to care and supporting standardized, equitable delivery systems are possible strategies to mitigate racial disparities in prostate cancer. Closer to home, policies to support diverse teams in the form of residency recruitment and selection are achievable steps that should be emphasized (see Figure). In doing so, we also move closer to improving the quality of urological care and addressing disparities in cancer outcomes.
- Cole AP, Lu C, Krimphove MJ, et al. Comparing the association between insurance and mortality in ovarian, pancreatic, lung, colorectal, prostate, and breast cancers. J Natl Compr Canc Netw. 2019;17(9):1049-1058.
- Krimphove MJ, Cole AP, Fletcher SA, et al. Evaluation of the contribution of demographics, access to health care, treatment, and tumor characteristics to racial differences in survival of advanced prostate cancer. Prostate Cancer Prostatic Dis. 2019;22(1):125-136.
- Alkhatib K, Labban M, Briggs L, et al. Does veteran status mitigate racial disparities in prostate cancer screening? Analysis of prostate specific antigen screening patterns in the 2018 Behavioral Risk Factor Surveillance System data. J Urol. 2022;207(5):993-1000.
- Cole AP, Herzog P, Iyer HS, et al. Racial differences in the treatment and outcomes for prostate cancer in Massachusetts. Cancer. 2021;127(15):2714-2723.
- Loeb S, Ravenell J, Gomez SL, et al. Racial concordance and trust in health communications: a randomized trial of videos about prostate cancer. J Clin Oncol. 2022;40(16_suppl):5014-5014.
- Gomez LE, Bernet P. Diversity improves performance and outcomes. J Natl Med Assoc. 2019;111(4):383-392.
- American Urological Association: The State of the Urology Workforce and Practice in the United States, 2021. Available at https://www.auanet.org/documents/research/census/2020-State-of-Urology-Workforce-Census-Book.pdf. Accessed June 24, 2022.
- Simons ECG, Ardines KEZ, Penaloza NG, et al. Racial and ethnic differences in medical student timing and perceived quality of exposure to urology. Urology. 2022;doi:10.1016/j.urology.2022.06.006
- Association of American Medical Colleges. Holistic Review, 2021. Available at https://www.aamc.org/services/member-capacity-building/holistic-review. Accessed June 24, 2022.
- Simons ECG, Diaz PA, Takele R, et al. Landscape analysis of the use of holistic review in the Urology Residency Match process. J Urol. 2022;207(suppl 5):e308.