Denver Health Medical Center is a safety net hospital in Denver, Colorado, and it is home to the vast majority of Denver’s vulnerable populations, including refugees and those who are socioeconomically disadvantaged, in prison, or with a stigmatizing complex medical condition. Historically, it is the birthplace of one of the major centers studying “multiple organ failure,” and where the term was coined by Ben Eiseman and Larry Norton.¹ Thereafter, Ernest E. Moore, surgeon-in-chief would classify the organ injury classification that has been adopted worldwide and facilitated the communication among providers when discussing trauma cases. Upon completing my training in early 2000, I was recruited to join the University of Colorado Urology faculty by my mentor, Dr Ernest E. Moore, the father of contemporary trauma surgery, and after my training with Drs Robert Flanigan and Louis Kavoussi I developed a vision of creating an efficient, robust minimally invasive (MIS) urology program at the county hospital. In addition to advanced cancer cases, patients at the county hospital were recovering from complex trauma and were suffering from illnesses most commonly found in developing countries, including tuberculosis in the urinary tract, parasitic infections, female mutilation, trauma, and complex urological cancers.

A month into my tenure, I was invited to join Mr Wellington Web, the mayor of Denver, and his team to develop a prostate cancer (PCa) screening program that targeted African American and Hispanic patients.² We planned several educational sessions and PSA blood draws with The Black Church Initiative, 100 Black Men, and several African American fraternities, as well as radio interviews and Question & Answer sessions with the Black community. Then we delved into the Hispanic community.

As a result of these interactions, I began to experience cultural challenges that hindered the success of these screening campaigns. Due to this experience, we conducted research on the cultural and socioeconomic impact of PCa on Asian Pacific Islanders, Hispanics, Latinos, and African Americans. As we progressed, we would understand the importance of developing MIS techniques to treat PCa.³

Retrospective medical chart reviews of 524 men were evaluated between January 2003 and January 2012, and 441 men underwent prostate needle biopsy for elevated PSA and/or abnormal digital rectal exam in our safety net hospital. A total of 273 men were diagnosed with PCa and 190 patients were treated for localized PCa. There were 65 African American, 53 Hispanic, and 72 Caucasian men. Hispanic men were typically older at biopsy (P = .042) while African American men presented with higher PSA (P = .005). A total of 83 men with private insurance from out of county were referred to our clinic specifically for laparoscopic radical prostatectomy (RP) or prostate cryoablation for the management of PCa.

Insurance Status

From the total of 441 patients who underwent prostate needle biopsy at our center, 49 (11.2%) patients had major private insurance coverage, with the majority of Caucasian men having this coverage. A majority of these private payers were from outside the county. A majority of the minority patients were considered residents and were largely enrolled in the indigent health care plan. In evaluating those over the age of 65 and potentially eligible for Medicare, another disparity is seen. Although the majority of coverage is through this entity, over 20% of the Hispanic population and 9% of the African American population were still covered by the indigent plan (P = .066). Meanwhile, African American and Hispanic men under 65 heavily relied on the indigent plan, with 70% and 61% enrollment, respectively. Thirty-one percent of Caucasian men under the age of 65 had private insurance plans.

Oncologic Profile and Outcome

Despite having similar PSA levels prior to prostate needle biopsy, Hispanic men had a much lower malignancy rate (P = .001).

Furthermore, African American men had the highest median PSA and Gleason scores. Caucasian men were more likely to be diagnosed with Gleason 6 PCa, while African American men were more likely to be diagnosed with Gleason 8 and 9. According to the D’Amico classification, African American men had more higher-risk cancers (P = .035), while Caucasian men had more low-risk cancers (P = .187). Consequently, African American men had more positive bone scans for metastatic workup (P < .001).

Treatment Selection of PCa

There was no difference in the selection of curative treatment for localized PCa (P = .775). However, there was a statistical difference in surgical management between African American and Caucasian men (P = .041).

Although we started a laparoscopic RP program in 2000, African American men preferred prostate cryoablation and radiation, while more Hispanic and Caucasian men underwent prostatectomy. According to the patients who were asked why they chose specific procedures, they included: open vs MIS, recovery time, and side effects (urinary incontinence, erectile dysfunction).

According to the study, several factors influence treatment selection, such as race, age, marital status, and eligibility for indigent programs. Among African American men, cryoablation appears to be a less invasive procedure and may influence their decision to undergo prostate surgery. Furthermore, we found that race interacts with social vulnerability to influence urologist recommendations for RP.⁴ Several studies have found that Black patients are less likely than White patients to undergo RP. Barriers to health care, comorbid illnesses, tumor characteristics, and patient preferences contribute to such disparities. We were unclear whether differences in urologist treatment recommendations also might play a role. In a randomized, 2 × 2 factorial design, we provided 2,000 urologists with a clinical vignette and asked them to recommend treatment for a healthy 70-year-old patient with low-risk, clinically localized PCa. The options included either RP, external beam radiotherapy, brachytherapy, cryotherapy, observation, or hormonal therapy. Within 4 otherwise identical vignettes, 2 variables were included: (1) patient race (Black vs White) and (2) social vulnerability (high-income and married vs low-income and widowed; Figure 1). Multivariable logistic regression was used to model the effects of patient race, social vulnerability, and their interaction on the recommendation of RP vs radiotherapy. We randomly selected urologists from a list of urologists who directly treat PCa. From a total of 6,104 urologists meeting these criteria, we randomly selected 2,000 for a mailed survey. Following Dillman survey methodology,⁵ and modeled on a previous survey by Fowler et al,⁶ we mailed each urologist a pretested survey, $10 cash incentive, and postage paid return envelope. Nonrespondents received reminder letters and up to 2 additional mailings of the survey. We had a response rate of 66.1% (n =1,313). There was an interaction between race and social vulnerability (P < 0.05) such that the highly vulnerable Black patient received an RP recommendation 14.4% fewer times than his less vulnerable counterpart; the difference between the 2 White patients was only 4.2%.

Figure 2. Exactly 1 year after the tragedy, survivors of the July 20, 2012, mass shooting got married in Denver.

The possibility that PCa is more lethal in Black patients may explain why race interacts with social vulnerability to influence urologist recommendations for RP.⁷ Thus, Black patients may be considered good candidates for RP. In contrast, Black race may heighten urologists’ concerns about poor surgical outcomes and follow-up after surgery. These findings affirm the importance of modeling interactions between race/ethnicity and other social variables in health disparities research.

Finally, on July 20, 2012, in Aurora, Colorado, a mass shooting occurred at a Century 16 theater showing The Dark Knight Rises at midnight.⁸ The shooter fired multiple firearms into the audience while setting off tear gas grenades. A total of 12 people were killed and 70 injured, 58 of them from gunfire. It was the deadliest shooting in Colorado since the Columbine High School massacre in 1999. It was the toughest night call I have ever taken. Fortunately, several victims had nonlethal wounds, but several of the survivors had retained bullets in their bodies. One particular patient suffered pelvic injuries from bullet fragments that were not removed but caused emotional pain and distress. From that experience I learned that the majority of gunshot wound victims expect us to remove the bullets.

Recently, Hayes et al described a similar phenomenon and created an innovative program that addresses the common gap in care for people who have suffered bullet-related injuries (BRIs), an experience that disproportionately affects young Black men.⁹ Over 85,000 emergency department visits for nonfatal bullet injuries are reported in the U.S. annually, and approximately 70% of patients are discharged to self-care without hospitalization.

Despite this, bullets often affect otherwise healthy people without prior wound care experience, leaving them ill-prepared to deal with their physical and emotional pain and wounds. Moreover, warranted mistrust and structural barriers create obstacles for people who have experienced BRIs, creating a body of unmet need in which neither the physical, psychological, nor social manifestations of BRIs are adequately addressed.

In summary, there is an enormous gap in our understanding of diversity, equity, and inclusion when we provide health care to minorities and vulnerable populations of patients. I believe that we, as health care providers, need to empathize and provide treatment that matches some of the patients’ expectations while respecting their culture and developing a more diverse health care workforce.

Finally, on a happy note, one of the victims of the tragic July 20, 2012, mass shooting got married exactly 1 year after that tragic day, and today they are proud parents of a baby boy (Figure 2).