Introduction and Barriers to Equity

In the United States, on average, Black men with prostate cancer (PCa) have an earlier onset of disease, present with more advanced stages, and have worse cancer-specific survival than their White counterparts.¹ Understanding the causes of these disparities is the first step toward ameliorating them. However, these disparities are multifactorial: a combination of inadequate access to care, modifiable environmental risk factors and exposures, and acquired epigenetic alterations. Besides patient-level factors, systems issues such as inadequate recruitment of underrepresented minorities in clinical trials, dissimilar screening, staging, and management patterns continue to widen the gap between patients and equitable health care.² The path toward equity is also hindered by mistrust in the medical system, lower rates of health literacy, social/cultural stigmas surrounding PCa, and a dearth of Black health care providers.^3-5 While advancements have been made in studying inequities in PCa care, significant barriers remain, particularly pertaining to social determinants of health (SDOH). Herein, we comment on the association of SDOH in PCa patients and propose strategies to help counteract disparities in both clinical scenarios and biomedical study design.

SDOH

Discussing health care disparities without acknowledging race as a social construct and the impact of structural racism would be irresponsible.^3,6 Because of racist policies, Black individuals have been subject to adverse social determinants which are directly correlated with health risks and outcomes. For example, redlining, a discriminatory federal policy, has led to higher exposure of air pollution and neighborhood deprivation in Black individuals—the demographic which leads the nation in rates of poor oncologic outcomes.⁷ With this frame of reference, socioeconomic factors and tumor biology have previously been considered separate factors contributing to gaps in PCa care. However, what is least understood is the complex interaction between either factor. Our understanding of this interplay between SDOH and biology continues to burgeon—overall, carcinogenesis and, ultimately, aggressive disease can result from epigenetic alterations resulting from structural inequities. However, the incorporation of SDOH into the study of PCa disparities is limited.

A recent meta-analysis evaluating the association of SDOH with PCa-specific mortality (PCSM) and overall survival (OS) among Black and White PCa patients demonstrated a significant race-SDOH interaction for both PCSM (P < .001) and OS (P = .03). Notably, in studies with minimal accounting for SDOH variables, Black patients had significantly higher PCSM compared to their White counterparts (P < .001). Meanwhile, for those with greater accounting for SDOH, PCSM was significantly lower among Black patients compared with White patients (P = .02).⁸ Taken together, these findings support a significant interaction between race and SDOH with respect to PCSM and OS among PCa patients, thus highlighting the importance of incorporating SDOH.

Potential Strategies

Clinical approach

An essential goal of health care delivery should be to build a therapeutic alliance between the patient and provider. However, this goal will remain lofty and likely unachievable without recognition and acknowledgment of the historical and contemporary acts that build mistrust in the institution of medicine. Historically, Black patients have been victims of medical experimentation. Additionally, when examining contemporary factors, Black men are less likely to be offered or enrolled in clinical trials. When enrolled in clinical trials, data suggest they are less likely to receive the study drug, as seen in the retrospective review of several castrate-resistant PCa phase 3 trials.⁹

Thus, to build this therapeutic alliance, providers must recognize the track record that has led us to this point and take steps to address this problem. The major step to addressing this issue is a true shared decision-making process, which seems straightforward. However, the Agency for Healthcare Research and Quality suggests using the SHARE approach in shared decision-making. This approach includes: Seeking patient participation, Helping the patient explore and compare treatment options, Assessing the patient’s values, Reaching a decision, and Evaluating that decision. To participate in a shared decision-making process, providers must have cultural competency, as patients’ values may vary across cultures, and recognize and discuss barriers that include SDOH, both of which benefit our patients.10,11

By revising the approach to patient interactions, providers can make substantial strides in addressing feelings of being unheard and medical mistrust. Adjusting our strategy and taking the time to understand patient hesitancy, providers will have an opportunity to discuss the dearth of representation in clinical trials, acknowledge historical acts, and ultimately emphasize the importance of representation in clinical trials, as these trials are the basis for developing treatment guidelines. Lastly, data suggest that communication, perceptions of care, and health outcomes are improved in race-concordant patient-provider relationships,^12,13 further highlighting the importance of diversification of the urological physician workforce.

Biomedical research and clinical trials

The underrepresentation of Black men in PCa clinical trials is well documented, resulting in limited generalizability.^2,5 To improve generalizability and address inequities, the medical field must make concerted efforts to recruit and enroll these patients through allocating funds, diversification of researchers and coordinators, community partnerships, increasing health literacy, and addressing medical mistrust. Designating resources, specifically toward minority-serving institutions, and providing adequate funds to develop and maintain the necessary research infrastructure are essential.¹⁴

Medical mistrust has contributed to poorer health literacy and suboptimal representation in research studies. This further hinders recruitment efforts, which are already ineffective at reaching minority patients. Building de novo trust from an academic center is challenging; therefore, patient outreach utilizing established, communal avenues can play a major role. Places of worship and religious leaders often significantly influence the Black community and serve as a gathering place for numerous community events. Proposed interventions suggest collaboration with trusted community organizations and leaders to recruit and educate patients on clinical trials and the importance of research involvement.¹⁵ Trials focused on recruiting Black patients would benefit from having a minority-specific recruitment plan and working to establish communication channels with trusted, integrated organizations within the community.¹⁶

Race and SDOH are closely intertwined; this association should not be avoided in scientific design, reporting, or clinical practices, but rather be the lens through which we work to improve the standard of care, equity, and, ultimately, outcomes for our patients.