Key Points on Disparities in Cancer Care - prIME Oncology
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eNewsletter

Key Points on Disparities in Cancer Care

Identifying & Correcting Cancer Care Disparities for Minority Populations: Importance of Non-Oncologist Participation

Racial Disparities in Prostate Cancer in 2017

Key Points:

  • African American men with prostate cancer have more aggressive disease, less early detection, and receive less aggressive treatment
  • US Preventative Services Task Force (USPSTF) screening guidelines are not optimal and may negatively impact long-term outcomes, particularly for minority and high-risk patients
  • Shared decision-making can improve the quality of prostate cancer screening and care for minority populations

Racial variation in the incidence and mortality of prostate cancer exists, with African American men 1.70 times more likely to be diagnosed with prostate cancer and 2.38 times more likely to die from their disease than white men.1 Multiple factors contribute to this racial variation, including disease factors (advanced grade, stage, volume, PSA),2 patient factors (education, demographics, comorbidities, access to health insurance and healthcare),3 and provider factors (experience, specialty, case volume, practice setting).4,5 African American men may have more aggressive prostate cancers, as evidenced by a younger mean age at presentation, higher Gleason Scores, and a higher disease stage at presentation compared to white men.2

“[We should] discuss benefits, harms, limitations of screening, consideration of patient preferences, and enable the patient to be empowered with informed decision-making.”
– A. Burnett

The Surveillance, Epidemiology, and End Results (SEER) database also showed that cancers that are most amenable to early detection, like prostate cancer, demonstrate the most striking racial variations, with poorer early detection in African American men.6 Traditional screening procedures involved prostate-specific antigen (PSA) assessment and digital rectal exam at age 50, and between ages 40 and 45 for patients who are high-risk.7 The 2012 prostate cancer screening recommendations from the US Preventive Services Task Force (USPSTF) did not endorse PSA-based screening, citing that the risks of overtreatment outweighed the benefits of early detection. However, new draft guidelines in 2017 recommend all men aged 55 years to 69 years should be informed of the benefits and harms of PSA screening and offered testing, with no screening for men aged ≥70.8,9 Controversy regarding optimal screening procedures persists and unfortunately, these guidelines are based on screening studies that lack ethnic diversity and that underrepresent the African American population.8 In addition, the USPSTF guidelines do not account for high-risk versus low-risk disease, which can be accurately assessed using clinical parameters.

Racial differences in treatment pattern also exist, including decreased use of aggressive therapy in African American men.10,11 Numerous systemic therapies are now available for metastatic prostate cancer, including hormonal therapies, chemotherapy, immunotherapy, and bone-targeted agents, and these strategies should be utilized effectively regardless of race or ethnicity. African Americans may also be subject to treatment selection bias, with increased likelihood of receiving “watchful waiting” and decreased likelihood of participating in shared decision-making.12,13 Appropriate use of active surveillance, as well as radiotherapy and radical prostatectomy, for localized disease requires careful balance of risk and benefits and should be based on prognostic indicators (PSA, digital rectal exam, and Gleason scores), as well as health status, life expectancy, and patient preferences.

Conclusions: Multidisciplinary care and shared decision-making are important to improve outcomes for African American men with prostate cancer.

References

  1. DeSantis CE, Siegel RL, Sauer AG, et al. Cancer statistics for African Americans, 2016: Progress and opportunities in reducing racial disparities. CA Cancer J Clin. 2016;66(4):290-308.
  2. Latini DM, Elkin EP, Cooperberg MR, Sadetsky N, Duchane J, Carroll PR. Differences in clinical characteristics and disease-free survival for Latino, African American, and non-Latino white men with localized prostate cancer: data from CaPSURE. Cancer. 2006;106(4):789-795.
  3. Zeliadt SB, Ramsey SD, Penson DF, et al. Why do men choose one treatment over another?: a review of patient decision making for localized prostate cancer. Cancer. 2006;106(9):1865-1874.
  4. Pollack CE, Bekelman JE, Epstein AJ, Liao K, Wong YN, Armstrong K. Racial disparities in changing to a high-volume urologist among men with localized prostate cancer. Med Care. 2011;49(11):999-1006.
  5. Pollack CE, Bekelman JE, Liao KJ, Armstrong K. Hospital racial composition and the treatment of localized prostate cancer. Cancer. 2011;117(24):5569-5578.
  6. Tehranifar P, Neuqut AI, Phelan JC, et al. Medical advances and racial/ethnic disparities in cancer survival. Cancer Epidemiol Biomarkers Prev. 2009;18(10):2701-2708.
  7. Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelines for the early detection of cancer, 2006. CA Cancer J Clin. 2006;56(1):11-25.
  8. Moyer VA; U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(2):120-134.
  9. USPSTF Prostate Cancer Screening 2012. www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate-cancer-screening. Accessed September 19, 2017.
  10. Zeliadt SB, Potosky AL, Etzioni R, Ramsey SD, Penson DF. Racial disparity in primary and adjuvant treatment for nonmetastatic prostate cancer: SEER-Medicare trends 1991 to 1999. Urology. 2004;64(6):1171-1176.
  11. Lyratzopoulos G, Barbiere JM, Greenberg DC, Wright KA, Neal DE. Population-based time trends and socioeconomic variation in use of radiotherapy and radical surgery for prostate cancer in a UK region: continuous survey. BMJ. 2010;340:c1928.
  12. Shavers VL, Brown ML, Potosky AL, et al. Race/ethnicity and the receipt of watchful waiting for the initial management of prostate cancer. J Gen Intern Med. 2004;19(2):146-155.
  13. Rim SH, Hall IJ, Fairweather ME, et al. Considering racial and ethnic preferences in communication and interactions among the patient, family member, and physician following diagnosis of localized prostate cancer: study of a US population. Int J Gen Med. 2011;4:481-486.

Evaluate and Claim Credit

Activity Overview

A recap of key points presented during the prIME Oncology satellite symposium held on August 1, 2017 in conjunction with the National Medical Association (NMA) Annual Convention & Scientific Assembly in Philadelphia, Pennsylvania. The eNewsletter’s content and the views expressed therein are those of the presenters and not of NMA.

This educational activity is specifically designed to meet the needs of internists, general practitioners, surgeons, obstetricians/gynecologists, urologists, gastroenterologists, and other healthcare providers.

After successful completion of this educational activity, participants should be able to:

  • Employ current evidence-based best practices regarding the utilization of diagnostic tools for patients with prostate cancer
  • Assess the implications of disparities on the diagnosis of patients with breast cancer and utilize strategies to overcome these disparities to improve outcomes
  • Integrate recent data regarding the potential influence of racial disparities on the diagnosis and, ultimately, clinical outcomes of patients with cervical cancer
  • Evaluate the implications of disparities on screening and diagnosis for patients with Lynch syndrome

This educational activity is supported by grants from Astellas; Lilly USA, LLC; and Merck and Co, Inc.

Continuing Education

prIME Oncology is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Key Points on Disparities in Cancer Care - prIME Oncology

prIME Oncology designates this enduring activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Each newsletter may provide the following credits:

  • Prostate Cancer: 0.25
  • Breast Cancer: 0.25
  • Cervical Cancer: 0.25
  • Lynch Syndrome: 0.25

Provider

This activity is provided by prIME Oncology.

Disclosure Information

Method of Participation

There are no fees for participating in and receiving CME credit for this activity. In order to receive credit, participants must successfully complete the online posttest and activity evaluation. Your participation in this CME activity will be recorded in prIME Oncology’s database. However, upon request, your CME credit certificate will be emailed to you. Technical requirements may be found under the Terms of Use.

A link to the posttest is available on the newsletter page.

In order to receive credit, participants must successfully complete the online posttest with 75% or higher.

Disclosure of Relevant Financial Relationships

prIME Oncology assesses relevant financial relationships with its instructors, planners, managers, and other individuals who are in a position to control the content of CME activities. Any potential conflicts of interest that are identified are thoroughly vetted by prIME Oncology for fairness, balance, and scientific objectivity of data, as well as patient care recommendations. prIME Oncology is committed to providing its learners with high-quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial entity.

The faculty reported the following financial relationships or relationships to products or devices they or their spouses/life partners have with commercial interest related to the content of this activity:

Dr Brown has disclosed that she has no relevant financial relationships to report. She has agreed to disclose any unlabeled/unapproved uses of drugs or products referenced in her presentation.

Dr Burnett has disclosed that he has received consulting fees from Astellas, Auxillium, Inc., Genomic Health Inc., Reflexonic LLC, and Vivus. He also received contracted research fees from American Medical Systems/Boston Scientific, Coloplast, Endo Pharmaceuticals, Medispec, and Pfizer. He has agreed to disclose any unlabeled/unapproved uses of drugs or products referenced in his presentation.

Dr Hall has disclosed that he has no relevant financial relationships to report. He has agreed to disclose any unlabeled/unapproved uses of drugs or products referenced in his presentation.

Dr Mitchell has disclosed that she has received fees for participation in advisory or review activities from Novartis. She has agreed to disclose any unlabeled/unapproved uses of drugs or products referenced in her presentation.

Dr Newman has disclosed that she has no relevant financial relationships to report. She has agreed to disclose any unlabeled/unapproved uses of drugs or products referenced in her presentation.

The employees of prIME Oncology have disclosed:

  • Lee Lokey, MD (medical director content reviewer/planner) – no relevant financial relationships
  • Zach Hartman, PhD (scientific content reviewer/planner) – Stock ownership in Advaxis, Inc., and Ariad Pharmaceuticals.
  • Amy Furedy, RN, OCN (scientific content reviewer/planner) – no relevant financial relationships
  • Jessica Mastrodomenico, MPH (editorial content reviewer) – no relevant financial relationships

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients’ conditions and possible contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Disclosure Regarding Unlabeled Use

This activity may contain discussion of published and/or investigational uses of agents that are not indicated by the US Food and Drug Administration or European Medicines Agency. Please refer to the official prescribing information for each product discussed for discussions of approved indications, contraindications, and warnings.