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
There are several potential explanations for these findings. First is
a consideration of racial discrimination in medical care. 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.
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
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. Similarly, in
equal access systems, no significant racial difference in overall survival
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.
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. 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
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
Moreover, even in studies that control for socioeconomic status, racial
differences in type of therapy persist. In addition, clinical factors
such as comor-bid conditions may account for some of the variation in care.
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.
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. 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
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