Race, socioeconomic status, and prostate cancer

The issue of whether race and socioeconomic status impact prostate cancer treatment outcomes is fraught with all sorts of pitfalls: emotional, statistical, political, medical, societal, you name it.

Some years ago, Tarman et al. published data demonstrating that, in an equal access health system (the US Military), there was no difference in outcomes to radical prostatectomy between patients based on socioeconomic status (SES) , but that patients of lower SES presented with higher grade cancer at the time of RP, and that African American race predicted higher risk for biochemical progression post-RP.

A couple of years later, in the same equal access health system, Johnstone et al. showed that, among men undergoing external beam radiation therapy (EBRT) as first-line treatment for prostate cancer, being African American had no overall impact on outcomes following EBRT. However, they did show that “Race appears to confer a negative prognosis …  in patients with advanced disease at presentation.”

Now comes a study from Tewari et al. suggesting that SES has a strong impact on long-term prostate cancer mortality in an equal access health system.

In their study, Tewari and his colleagues set out to examine the impact of socioeconomic factors on survival in black and white patients with local or regional prostate cancer. Their database comprise all 2,046 men diagnosed with localized prostate cancerbetween 1990 and 2000 at the Henry Ford Health System and the Henry Ford Medical Group, two equal access health centers in Michigan.

Data about the patients were gathered from multiple sources on their stage, grade, age at diagnosis, socioeconomic status, treatment given, comorbidities, and vital statistics. The endpoints were overall survival and cancer-specific survival.

The results of their study were as follows:

  • Of the 2,046 cases, 1243 were white and 803 were black.
  • Black patients were more likely to have lower incomes, a higher baseline PSA level, and more comorbidities than white patients.
  • Black patients were also more likely to undergo radiotherapy and less likely to undergo radical prostatectomy.
  • Black patients had significantly higher cancer-specific mortality (hazard ratio 1.47) and overall mortality (hazard ratio 1.29) than white patients.
  • However, after adjustments for insurance status and income, there appeared to be no significant differences in cancer-specific mortality (hazard ratio 1.04) or overall mortality (hazard ratio 0.96) between the two groups.

The authors conclude that, at least in this cohort, “socioeconomic factors were sufficient to explain the disparity in survival between white and black patients.”

How do we correlate these different data? Is it even appropriate to try? It is apparent from a multitude of studies that for some reason (still not fully understood) men of African descent are at greater risk for earlier onset of prostate cancer than men of Caucasian descent. Based on Tewari’s data, it also seems to be the case that, despite diagnosis and treatment at an equal access health system, lower SES is associated with a higher risk for long-term prostate cancer-specific mortality.

How can we interpret these data? Is it possible that the Henry Ford Health System may not be as “equal” in access as it would like to believe? Are the socioeconomic factors really the problem, or are they just associated data? Do the facts that, in the Henry Ford study, black men present with higher PSA levels and more co-morbidities reflect less willingness to see physicians for regular check-ups? Are there dietary issues at play here? Or is there an unwillingness in the African American community to come back for further treatment early enough when first line therapy fails?

The sad truth is that we still haven’t really got to the core of some of the issues that appear to be relevant to the impact of race and socioeconomic status on risk for disease onset or mortality. Prostate cancer is a relatively minor example of the health problems associated with socioeconomic status and ethnicity in the USA today, compared to things like heart disease and diabetes. It is long past time for us to have developed a health system that offered high quality care for all, regardless of race or socioeconomic status — and made sure that people understood how to get the best care from that system.

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