Racial Disparities in Prostate Specific Antigen Screening and Referral to Urology in a Large, Integrated Health Care System: A Retrospective Cohort Study

Abstract

Purpose: Contemporary trends and racial disparities in prostate cancer screening and referral to urology for prostate cancer risk are not well characterized, despite consensus that Black men are at higher risk for poor prostate cancer outcomes. The objective of this study was to characterize current racial disparities in prostate cancer screening and referral from primary care to urology for prostate cancer concern within our large, integrated health care system. Materials and Methods: This retrospective cohort study used data from Atrium Health's enterprise data warehouse, which includes patient information from more than 900 care locations across North Carolina, South Carolina and Georgia. We included all men seen in the ambulatory or outpatient setting between 2014 and 2019 who were 40 years old. Clinical and demographic data were collected for all men, including age and race. Racial outcomes were reported for all groups with >2% representation in the population. Between-group comparisons were determined using chi-squared analysis, Wilcoxon rank sum testing and multivariable logistic regression, with significance defined as p <0.05. Results: We observed a significant decrease in prostate specific antigen testing across all age and racial groups in a cohort of 606,985 men at Atrium Health, including 87,189 Black men, with an overall relative decline of 56%. As compared to White men, Black men were more likely to undergo prostate specific antigen testing (adjusted OR 1.24, 95% CI 1.22e1.26) and be referred to urology for prostate cancer (adjusted OR 1.94, 95% CI 1.75e2.16). Conclusions: There was a continued significant decline in prostate cancer screening between 2014 and 2019. Despite having modestly elevated odds of being screened for prostate cancer compared to White men, Black men are relatively underscreened when considering that those who undergo prostate specific antigen screening are more likely to be referred by primary care to urology for additional prostate cancer diagnostic evaluation.

Evaluation of Social Determinants of Health and Prostate Cancer Outcomes Among Black and White Patients

“… 6 , 7 In contrast, Black men with prostate cancer in the US consistently have disparities in SDOH, such as decreased access to health care, reduced prostate-specific antigen screening, economic instability, receipt of less guideline-concordant cancer care, greater number of comorbid conditions, lower likelihood of treatment of comorbid conditions, reduced curative-intent treatment, and reduced access to high-volume centers, all of which reflect SDOH that can be associated with health outcomes. 8 , 9 , 10 , 11 , 12 , 13 …”

“…6,7 In contrast, Black men with prostate cancer in the US consistently have disparities in SDOH, such as decreased access to health care, reduced prostate-specific antigen screening, economic instability, receipt of less guideline-concordant cancer care, greater number of comorbid conditions, lower likelihood of treatment of comorbid conditions, reduced curative-intent treatment, and reduced access to highvolume centers, all of which reflect SDOH that can be associated with health outcomes. [8][9][10][11][12][13] There continues to be considerable heterogeneity in the extent, and even existence, of racial disparities in prostate cancer survival outcomes in the literature. Large registry studies have found profound racial disparities in prostate cancer outcomes.…”

Benign Prostatic Hyperplasia in African American Men Merits Greater Consideration in Academic Medicine

“…Unfortunately, the medical literature consistently supports the concerning reality that African American men are insufficiently screened for both BPH and prostate cancer [29]. Consistent with other healthcare issues, African American men are more likely to be disproportionately impacted by insufficient healthcare literacy [30][31][32].…”

“…It contains seven questions related to BPH symptoms and one question related to the patient's perceived quality of life. BPH symptom severity is proportionate to the IPSS score, which ranges from 0 to 35 and categorizes symptoms as mild (1-7), moderate (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19), or severe (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35). The IPSS survey is widely used in Urology and the AUA also encourages its use in primary care settings.…”

Prostate-specific antigen response and clinical progression-free survival in Black and White men with chemotherapy-naïve metastatic castration-resistant prostate cancer treated with enzalutamide in a real-world setting

“…In the United States (US), Black men are 1.75 times more likely to be diagnosed with and twice as likely to die of prostate cancer (PC) than White men [1]. Disparities in the incidence and mortality rate of PC and in screening and access to treatment between Black and White men are well documented [1][2][3][4][5]. The racial disparities in PC are likely multifactorial, including social, cultural, and biological determinants of health [3,[6][7][8].…”