Need and Importance

The present landscape of health care disparities entails understanding the complex associations between biological and non-biological determinants of health.¹ For instance, prostate cancer (PC) disparities have been well recognized, with African Americans having the highest incidence and mortality.² Nevertheless, among other ethnic groups, significant variability exists.³

Regarding Hispanics, Puerto Rican (PR) men have a higher PC mortality compared to non-Hispanic White men or Hispanic men living in the continental U.S.⁴ Indeed, PC mortality among PR men is second only to African Americans. However, PC in Puerto Rico remains largely uninvestigated. Puerto Rico has had more than 500 years of population admixture across people of African, Indigenous, and European descent.⁵ Across Hispanic subgroups, PRs have one of the highest average levels of genetic African ancestry at 23.6%.⁶ For comparison, men of Mexican descent average 4%-6% genetic African ancestry.⁶ Therefore, the PR population is unique from other Hispanic communities in its genetic composition as well as its social and political environment.

It is important to note that the Commonwealth of Puerto Rico is a U.S. territory with approximately 3.2 million residents. As a U.S. territory since 1898, there are political restrictions on federal voting, representation, administration, and health care funding.⁷ Health care makes up 20% of the PR economy, and differences in the allocation of funds to the territory of Puerto Rico likely impact patient access to care.⁸

What We Found

Access to care is a key factor in health care disparities and any survivorship disadvantage among PR men may derive from differences in access to health care or treatment. However, to what degree these findings are influenced by access to care are unclear. To overcome this concern, we evaluated the outcomes among PR men undergoing radical prostatectomy. We utilized the SEARCH (Shared Equal Access Regional Cancer Hospital) database, a multicenter and multiethnic database derived from the Veterans Administration (VA) health system—the largest integrated health system in the country. By doing this, we sought to minimize differences in access to care and, by focusing on men with early stage disease treated aggressively, we further minimized differences in practice patterns that may affect outcomes. Despite the suggestion of less aggressive and less advanced disease, on crude analysis, PR men had a significantly higher risk of PC death (log-rank P = .006). After adjusting for age, PSA, and BMI, PC cases in Puerto Rico had a 75% higher risk of PC-specific death (HR=1.75 [1.21, 2.52], P = .003). Additional adjustment for PC grade at diagnosis increased the strength of this association (HR=2.53 [1.74-3.68], P < .001). Overall, PR men diagnosed with PC and receiving radical prostatectomy for clinically localized disease through an equal access health care system were at greater risk for PC-specific mortality, despite having equal or better prognostic markers. Whether genetic background, comorbidity status, or environmental exposures drive the significantly poorer PC outcomes in PR men is unknown.

Therefore, future studies need a multilevel approach, considering the interaction of different factors that may contribute to this disparity. A genomic and molecular research approach may offer additional treatment perspectives to reduce the disparity burden. This should also include social, political, and economic structures that could contribute to the health status and treatment outcomes of the population. PRs have been impacted by a challenging economic recession associated to a massive growing debt. The COVID-19 outbreak has worsened the ongoing economic crisis in Puerto Rico by creating “parallel pandemics”⁹ that have exacerbated health inequalities. In addition, hurricanes Irma and Maria created a near total interruption of services, displaced large segments of the population, and impacted cancer care and surveillance infrastructure.¹⁰

Hurricane Maria and the COVID-19 pandemic are not the sole concerns for health differences between PR adults and Americans on the mainland. PR adults received less preventive care, including fewer cancer screenings, vaccines, and immunizations.¹¹ Although PRs pay Medicare and Federal Insurance Contributions Act taxes at the same rate as residents in the 50 U.S. states, the Medicare Advantage program is supported only at 60% compared to the states⁷ and the quality of care in the territory of Puerto Rico may be lower than in the states.¹²

There are also medical workforce issues: PR physicians reimbursement is 40% lower,⁷ and most physician practices, including urology practices, are in a solo practice, which imposes a higher operational cost. Consider that there is an overall shortage of health care providers in Puerto Rico, with 5,000 physicians leaving the island for better opportunities.¹³ This shortage extends to urology, with the urologist:patient ratio at 1:45,000 in Puerto Rico compared to the 1:34,323 ratio in the mainland U.S.¹⁴ It thus seems that PR urological care faces a dire future. Projected workforce demographics raises another alarm, as 50% of urologists in Puerto Rico are over 65 years compared with 29.8% of the urology workforce in the mainland U.S.¹⁵ With these genetic, social, environmental, and governmental challenges, the question remains how best to improve PC and general urological care in Puerto Rico.

Future Challenges and Needs

PRs face disparities in PC and an impending health care crisis. There is no doubt that national- and federal-level interventions are needed to unravel the complex reasons for the existing PC mortality disparity and advance both future research and clinical practices. Strategies may include education of lawmakers of the current health care disparities, identification of barriers and needs of the upcoming generation of urologists, the development of culturally appropriate evidence-based interventions, fostering strategic collaborations, and increasing the participation of PRs in clinical trials with the long-term goal to improve health equity in this underserved minority population. Continued efforts are needed to understand the current PC mortality disparity, especially among men in Puerto Rico who tend to have the worst outcomes. The geographical location of the U.S. citizens in Puerto Rico should not be a limitation to achieve health equity, rather an opportunity to create an inclusive health care system for future generations to come.

Disclaimer

The contents of this publication do not represent the views of the VA Caribbean Healthcare System, the Department of Veterans Affairs or the United States Government.

Acknowledgment of VA Employment

LGR is employed as Urology attending staff, VA Caribbean Healthcare System, San Juan, Puerto Rico.