Emerging racial disparities among Medicare beneficiaries and Veterans with metastatic castration-sensitive prostate cancer

Daniel J George; Neeraj Agarwal; Krishnan Ramaswamy; Zachary Klaassen; Rhonda L Bitting; David Russell; Rickard Sandin; Birol Emir; Hongbo Yang; Wei Song; Yilu Lin; Agnes Hong; Wei Gao; Stephen J Freedland

doi:10.1038/s41391-024-00815-1

Emerging racial disparities among Medicare beneficiaries and Veterans with metastatic castration-sensitive prostate cancer

Prostate Cancer Prostatic Dis. 2024 Apr 2. doi: 10.1038/s41391-024-00815-1. Online ahead of print.

Authors

Daniel J George¹, Neeraj Agarwal², Krishnan Ramaswamy³, Zachary Klaassen⁴, Rhonda L Bitting^{5

6}, David Russell³, Rickard Sandin⁷, Birol Emir³, Hongbo Yang⁸, Wei Song⁸, Yilu Lin⁹, Agnes Hong^{3

10}, Wei Gao⁸, Stephen J Freedland^{11

12}

Affiliations

¹ Department of Medicine, Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA. Daniel.George@duke.edu.
² Department of Internal Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
³ Pfizer Inc., New York, NY, USA.
⁴ Department of Surgery, Medical College of Georgia at Augusta University, Georgia Cancer Center, Augusta, GA, USA.
⁵ Department of Medicine, Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA.
⁶ Department of Medicine, Durham VA Medical Center, Durham, NC, USA.
⁷ Pfizer AB, Sollentuna, Sweden.
⁸ Analysis Group, Inc., Boston, MA, USA.
⁹ Department of Health Policy and Management, Tulane University, New Orleans, LA, USA.
¹⁰ Formerly of Astellas Pharma Inc., Northbrook, IL, USA.
¹¹ Section of Urology, Durham VA Medical Center, Durham, NC, USA.
¹² Department of Urology, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

PMID: 38565911
DOI: 10.1038/s41391-024-00815-1

Abstract

Background: Previous studies have shown that Black men receive worse prostate cancer care than White men. This has not been explored in metastatic castration-sensitive prostate cancer (mCSPC) in the current treatment era.

Methods: We evaluated treatment intensification (TI) and overall survival (OS) in Medicare (2015-2018) and Veterans Health Administration (VHA; 2015-2019) patients with mCSPC, classifying first-line mCSPC treatment as androgen deprivation therapy (ADT) + novel hormonal therapy; ADT + docetaxel; ADT + first-generation nonsteroidal antiandrogen; or ADT alone.

Results: We analyzed 2226 Black and 16,071 White Medicare, and 1020 Black and 2364 White VHA patients. TI was significantly lower for Black vs White Medicare patients overall (adjusted odds ratio [OR] 0.68; 95% confidence interval [CI] 0.58-0.81) and without Medicaid (adjusted OR 0.70; 95% CI 0.57-0.87). Medicaid patients had less TI irrespective of race. OS was worse for Black vs White Medicare patients overall (adjusted hazard ratio [HR] 1.20; 95% CI 1.09-1.31) and without Medicaid (adjusted HR 1.13; 95% CI 1.01-1.27). OS was worse in Medicaid vs without Medicaid, with no significant OS difference between races. TI was significantly lower for Black vs White VHA patients (adjusted OR 0.75; 95% CI 0.61-0.92), with no significant OS difference between races.

Conclusions: Guideline-recommended TI was low for all patients with mCSPC, with less TI in Black patients in both Medicare and the VHA. Black race was associated with worse OS in Medicare but not the VHA. Medicaid patients had less TI and worse OS than those without Medicaid, suggesting poverty and race are associated with care and outcomes.