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Racial Variation in Prostate Cancer Care Explored

Racial Variation in Prostate Cancer Care Explored

In the United States, racial variations have been documented in the incidence, mortality, and clinical management of cancers of the breast, colon, lung, and prostate.[1-4] In conjunction with similar findings from nonmalignant diseases, such as cardiovascular and cerebrovascular disease, these data suggest that racial variations in medical care are widespread.[5-8] However, few empirical studies explain why these racial variations exist at all.

There are several potential explanations for these findings. First is a consideration of racial discrimination in medical care.[9] Second, differences in socioeconomic status and income, rather than race, might be important factors. For example, racial differences in incidence and survival for some cancers have been linked to socioeconomic status.[10-12] Socioeconomic status may also account for variations in patterns of care.

Third, clinical factors may differ according to race/ethnicity, including disease pathophysiology, stage at presentation, or comorbid conditions that may be contraindications to some therapies or otherwise modify the choice of treatment. Fourth, there may be racial or cultural differences in patient preferences for care.

Understanding the extent of, and factors associated with, racial variations in the care of men with prostate cancer is especially important. Recent advances in prostate cancer screening have resulted in higher rates of early-stage disease among whites more so than blacks.

The Concept of Race

Race is regarded as a social concept that reflects historical social and economic events and not as a biological entity.[13-15] Indeed, some health researchers contend that race has no biological meaning and should be abandoned as a variable in analyses, particularly because the concept has been used in the past to bolster racist arguments of the purported inherent superiority of some racial groups.[16,17]

The socioeconomic aspects of race have been evaluated previously, while potential biological aspects have been virtually ignored.[18,19] Although race is intimately intertwined with socioeconomic status (at least in the US), the two terms reflect different concepts.[20,21]

For example, race may also be an indicator of genetic proclivities for cancer development, a proxy for economic factors, eg, ability to pay for care, or a marker for cultural orientation, eg, patient preferences for certain therapies or misunderstandings about some therapies.

The policy implications of these alternative explanations are widely different, varying from educational strategies, health care financing reform, or program targeting to high-risk populations.

Among males, prostate cancer is second only to lung cancer in incidence and mortality, with significant racial differences in both factors.[1] In 1992, the age-adjusted incidence rate for prostate cancer was 187.6 per 100,000 for blacks vs 139.4 per 100,000 for whites, yielding an overall rate ratio of 1.3.

The age-adjusted mortality rate for prostate cancer for 1988 to 1992 was 53.5 per 100,000 for blacks vs 24.0 per 100,000 for whites, a mortality rate ratio of 2.2. This is one of the largest ratios for site-specific cancer mortality.

Blacks consistently present at a later stage of prostate cancer. However, adjusting for stage at presentation does not eliminate the racial disparities in survival rates; rather, the survival gap between blacks and whites demonstrates a broadening with advanced stage.

Patterns of Care

Racial/ethnic differences are apparent in the care of prostate cancer patients. For example, black patients are substantially more likely than whites to receive hormonal therapy alone but are less likely to undergo prostatectomy alone. This pattern appears to persist over time.

There is a relatively extensive and consistent literature regarding the role of clinical and socioeconomic factors in explaining racial differences in types of prostate cancer therapy, but no literature on the importance of either patient preferences or the patient-physician interaction.

It is not known if differences in care contribute to the lower survival rates among blacks. Some studies have reported that when treatments are similar between blacks and whites, outcomes are similar. Among patients on standard oncology protocols, there is uniformity in evaluation and treatment, as well as overall survival and disease-free survival.[22] Similarly, in equal access systems, no significant racial difference in overall survival is reported.[23,24]

However, the literature linking specific treatments with outcomes according to race does not consistently indicate these findings. In one study, time to recurrence was shorter among the black vis-à-vis the white patients who underwent a radical prostatectomy.[25]

Stage at Presentation

Studies suggest that stage at presentation is a primary explanation of the racial difference in therapy. Among patients in the Virginia Cancer Registry who have local or regional disease, blacks are more likely than whites to receive either no treatment or hormonal therapy but less likely to receive either surgery or radiation.[26] With adjustment for socioeconomic, clinical, and health care system characteristics, there is no racial difference in either the likelihood of receiving any treatment versus no treatment or in receiving hormonal therapy or orchiec-tomy versus surgery or radiation.

However, SEER data indicate that, among localized disease patients, blacks are only two thirds as likely to receive radical prostatectomy or radiation.[27]

Ability to Pay

Given the general importance of ability to pay for care in gaining access to health care, it is reasonable to expect that socioeconomic status is an important determinant of therapy. However, review of the evidence from federal and non-federal patterns of care studies suggest that ability to pay may have little or no role in explaining racial variations in the types of therapy for prostate cancer.

Within the health care systems of the Veterans Health Administration or Department of Defense medical centers, financial incentives for providing or withholding care are minimal. However, one patterns of care study found racial variations in care similar to those seen in the nonfederal health care sector.[23]

Moreover, even in studies that control for socioeconomic status, racial differences in type of therapy persist.[26] In addition, clinical factors such as comor-bid conditions may account for some of the variation in care.[26]

Finally, ability to pay is just one dimension of socioeconomic status. Other dimensions of socioeconomic status, such as education or knowledge, may be worth exploring as possible additional factors that have a role in explaining the racial differences in prostate cancer therapy.

Variations in Patient Preferences

Neither racial variations in patient preferences, knowledge, and beliefs nor the role of the patient's race in the patient-physician decision-making process has been thoroughly investigated as a potential explanation of the observed racial differences in patterns of care.

Recent investigations suggest that blacks are less likely to see themselves as being at high risk of prostate cancer and may have a more pessimistic view of the impact of prostate cancer on quality of life and of the prognosis.[28-30] Such attitudes may indirectly account for the racial differences in the therapies used by influencing when in the natural history of this disease black patients present.

Future Research

Given that racial variation in the clinical stage at presentation primarily explains the observed differences in use of therapies, there are at least two compelling avenues for future investigations of racial differences in the treatment of prostate cancer.

One is racial differences in disease pathophysiology and their implications for screening and early detection programs. Blacks may experience a more aggressive form of prostate cancer.[31] There is a long history of epidemiological studies that document a higher incidence and earlier onset of prostate cancer among blacks.[32-36]

Also, time to recurrence may be shorter in black than in white prostate cancer patients, despite similar treatment and similar clinical stage at presentation.[22,25] Finally, latent prostate cancers are greater in volume among blacks than whites.[37,38]

Even if a more aggressive form of prostate cancer does not afflict blacks, studies show consistently that blacks present at a later clinical stage of disease than whites even in equal access systems such as the Veterans Health Administration and Department of Defense.[23,39,40]

Existing evidence, which is far from sufficient, indicates that blacks do not perceive themselves to be at high risk for prostate cancer, while the epidemiology of prostate cancer clearly indicates that they are at high risk. Moreover, blacks may be delaying evaluation because of fears regarding disease prognosis.[28,30]

Prostate cancer is one of several cancers that affect US racial and ethnic groups differently, with blacks experiencing a higher incidence and mortality rate than whites. Black patients with prostate cancer are less likely to receive definitive therapy. This pattern of care difference appears to be attributable primarily to the later clinical stage of disease at presentation; socioeconomic considerations, which relate to access to care, appear to play a lesser role.

Other patient-related factors, for example, preferences for certain therapies, have not been well studied; consequently, their ability to explain racial variations in treatment is unclear.

Potential areas for future research should focus on the reasons for the detection of the disease at a later clinical stage and, hence, its worse prognosis.


1. Wingo PA, Bolden S, Tong T, et al: Cancer statistics for African Americans. CA-A Cancer J Clin 46:113-125, 1996.

2. Ries LAG, Miller BA, Hankey BF, et al (eds): SEER Cancer Statistics Review, 1973-91. NIH Pub. 94-2789. Bethesda, Md, National Cancer Institute, 1994.

3. Cooper GS, Yuan Z, Landefeld CS, et al: Surgery for colorectal cancer: Race-related differences in rates and survival among Medicare beneficiaries. Am J Public Health 86:582-586, 1996.

4. Mettlin CJ, Murphy G: The National Cancer Data Base report on prostate cancer. Cancer 74:1640-1648, 1994.

5. Horner RD, Matchar DB, Divine GW, et al: Racial variation in ischemic stroke-related physical and functional impairments. Stroke 22:1497-1501, 1991.

6. Whittle J, Conigliaro J, Good CB, et al: Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system. N Engl J Med 329:621-627, 1993.

7. Oddone EZ, Horner RD, Monger ME, et al: Racial variation in the rates of carotid angiography and endarterectomy in patients with stroke and transient ischemic attack. Arch Intern Med 153:2781-2786, 1993.

8. Horner RD, Oddone EZ, Matchar DB: Theories explaining racial differences in the utilization of diagnostic and therapeutic procedures for cerebrovascular disease. Milbank Q 73:443-462, 1995.

9. Geiger HJ: Race and health care--an American dilemma? N Engl J Med 335:815-816, 1996.

10. McWhorter WP et al: Contribution of socioeconomic status to black/white differences in cancer incidence. Cancer 63:982-987, 1989.

11. Gorey KM, Vena JE: Cancer differentials among US blacks and whites: Quantitative estimates of socioeconomic-related risks. J Natl Med Asso 86:209-215, 1994.

12. Cella DF et al: Socioeconomic status and cancer survival. J Clin Oncol 9:1500-1509, 1991.

13. Watts ES: The biological race concept and diseases of modern man, in Rothschild HR (ed): Biocultural Aspects of Disease, pp 3-23. New York, Academic Press, Inc, 1981.

14. Cooper R, David R: The biological concept of race and the application to public health and epidemiology. J Health Polit Policy Law 11:97-116, 1986.

15. Witzig R: The medicalization of race: Scientific legitimization of a flawed social construct. Ann Intern Med 125:675-679, 1996.

16. Osborne NG, Feit MD: The use of race in medical research. JAMA 267:275-279, 1992.

17. Schulman KA et al: The roles of race and socioeconomic factors in health services research. Health Serv Res 30:179-195, 1995.

18. Williams DR: The concept of race in Health Services Research: 1966-1990. Health Serv Res 29:261-274, 1994.

19. Jones CP, LaVeist TA, Lillie-Blanton M: "Race" in the epidemiologic literature: An examination of the American Journal of Epidemiology, 1921-1990. Am J Epidemiol 134:1079-1084, 1991.

20. Nickens HW: The role of race/ethnicity and social class in minority health status. Health Serv Res 30:151-162, 1995.

21. Lillie-Blanton M et al: Racial differences in health: Not just black and white but shades of gray. Ann Rev Public Health 17:411-448, 1996.

22. Roach M et al: The prognostic significance of race and survival from prostate cancer based on patients irradiated on Radiation Therapy Oncology Group protocols (1976-1985). Int J Radiat Oncol Biol Phys 24:441-449, 1992.

23. Optenberg SA et al: Race, treatment, and long-term survival from prostate cancer in an equal-access medical care delivery system. JAMA 274:1599-1605, 1995.

24. Fowler JE, Terrell F: Survival in blacks and whites after treatment for localized prostate cancer. J Urol 156:133-136, 1996.

25. Moul JW et al: Black race is an adverse prognostic factor for prostate cancer recurrence following radical prostatectomy in an equal access health care setting. J Urol 155:1667-1673, 1996.

26. Desch CE et al: Factors that determine the treatment for local and regional prostate cancer. Med Care 34:152-162, 1996.

27. Schapira MM, McAuliffe TL, Nattinger AB: Treatment of localized prostate cancer in African-American compared with Caucasian men: Less use of aggressive therapy for comparable disease. Med Care 33:1079-1088, 1995.

28. Demark-Wahnefried W et al: Knowledge, beliefs, and prior screening behavior among blacks and whites reporting for prostate cancer screening. Urology 46:346-351, 1995.

29. Price JH, Colvin TL, Smith D: Prostate cancer: Perceptions of African-American males. J Natl Med Asso 85:941-947, 1993.

30. Price JH et al: Black American's perceptions of cancer: A study utilizing the Health Belief Model. J Natl Med Asso 80:1297-1304, 1988.

31. Morton RA: Racial differences in adenocar-cinoma of the prostate in North American men. Urology 44:637-645, 1994.

32. Whitmore WF: Localized prostatic cancer: Management and detection issues. Lancet 334:1263-1267, 1994.

33. Nomura AMY, Kolonel LN: Prostate cancer: A current perspective. Epidemiol Rev 13:200-227, 1991.

34. Dayal HH, Polissar L, Dahlberg S: Race, socioeconomic status, and prostatic cancer. J Natl Cancer Inst 74:1001-1006, 1985.

35. Dayal HH, Chiu C: Factors associated with racial differences in survival for prostatic carcinoma. J Chronic Dis 35:553-560, 1982.

36. Ernster VL et al: Prostatic cancer: Mortality and incidence rates by race and social class. Am J Epidemiol 107:311-320, 1978.

37. Whittemore AS, Keller JB, Betensky R: Low-grade, latent prostate cancer volume: Predictor of clinical cancer incidence? J Natl Cancer Inst 83:1231-1235, 1991.

38. Guileyardo JM et al: Prevalence of latent prostate carcinoma in two U.S. populations. J Natl Cancer Inst 65:311-316, 1980.

39. Powell IJ, Schwartz K, Hussain M: Removal of the financial barrier to health care: Does it impact on prostate cancer at presentation and survival? A comparative study between black and white men in a Veterans Affairs system. Urology 46:825-830, 1995.

40. Brawn PN et al: Stage of presentation and survival of white and black patients with prostate carcinoma. Cancer 70:2569-2573, 1993.

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