Latin-American PCa patients less likely to receive definitive treatment

Latin-American men are less likely than non-Latin-American Caucasian men to receive guideline-recommended definitive treatment for high-risk localized prostate cancer, according to a recent study (J Natl Compr Canc Netw 2018; 16:1353-60).

All men with high-risk localized prostate cancer and a life expectancy of greater than 5 years should receive definitive therapy, according to National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Yet, in this study of 2,421 Latin-American and 8,636 non-Latin-American Caucasian men with high-risk localized disease in the California Cancer Registry (2010 to 2014), Latin-Americans were 21% less likely to receive recommended treatment.

The authors eliminated the disparity after adjusting for sociodemographic factors, finding that Latin-Americans’ prostate cancer treatment seemed impacted by several sociodemographic and other nonclinical factors, including neighborhood socioeconomic status, health insurance, marital status, and care at a National Cancer Institute (NCI)]-designated cancer center, according to the study’s lead author Daphne Lichtensztajn, MD, MPH, of the University of California, San Francisco department of epidemiology and biostatistics.

Having health insurance, for example, was a factor in whether Caucasians and Latin-Americans received definitive care, but it was a much bigger factor among Latin-American men. While uninsured non-Latin-American Caucasian men were 37% less likely to receive definitive treatment than non-Latin-American Caucasians with insurance, uninsured Latin-Americans were 66% less likely to undergo definitive treatment compared to Latin-Americans with health insurance.

“While we expected to find an association between lack of insurance and under-treatment, the difference in the magnitude of this effect between Latinos and non-Latinos was surprising,” Dr. Lichtensztajn said.

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The authors also found that non-Latin-American Caucasian men with high-risk localized prostate cancer were 57% more likely to receive recommended treatment if they went to an NCI-designated cancer center. There was no such increase in the odds of receiving definitive treatment for Latin-American men seeking care at these cancer centers.

That, too, was surprising, according to Dr. Lichtensztajn.

“NCI-designated cancer centers are generally associated with higher quality of care and greater availability of ancillary services, such as patient navigators and translators, which would have been expected to result in a greater likelihood of receiving definitive treatment, as it did for the non-Latino men,” she said.

Latin-Americans make up the nation’s largest minority group. The disparity in high-risk localized prostate cancer care is a multifaceted issue that will require efforts at various levels in health care, according to Dr. Lichtensztajn.

Next: “At the provider level, the key to narrowing this gap is taking a patient-centered approach to care"“At the provider level, the key to narrowing this gap is taking a patient-centered approach to care, which is something I think urologists already strive to do,” she said. “When seeing Latino patients, urologists should keep in mind that there may be additional language, cultural, or socioeconomic factors at play. And urologists should make an attempt to specifically elicit any concerns in those areas, as the patients themselves may be hesitant to share that information unprompted.”

Whenever possible, providers should make use of trained interpreters and make Spanish-language and culturally-appropriate materials available, according to Dr. Lichtensztajn.

Dr. Lichtensztajn said that several organizations provide Spanish-language information on prostate cancer treatment and decision-making online, including the American Cancer Society and the NCI.

“Providers should also be vigilant to the manner in which they present treatment options to Latino patients to make sure they are not subconsciously making assumptions about patient preference based on ethnicity and inadvertently modifying their message,” Dr. Lichtensztajn said. “And while urologists may feel everything was presented clearly to the patient, it is important to verify this by assessing the patient’s interpretation and understanding of the topics discussed and resolve any misconceptions.”

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It’s critical that the urologist elicits from the patient not only his treatment preferences, but also any barriers he perceives that could impede obtaining treatment, such as insurance, transportation, family, or employment. Referrals to support services, such as social workers and patient navigators, as well as patient networks and community resources, can be extremely valuable in this respect, according to Dr. Lichtensztajn.

Dr. Lichtensztain said that consequences of the unequal care are that Latin-American men initially diagnosed with high-risk localized disease are at higher risk of symptomatic disease progression and prostate cancer mortality than non-Latin-American Caucasian men.

While this study concentrated on a database of patients in California, similar treatment disparities for Latin-Americans have been reported by other researchers using nationwide data, according to Dr. Lichtensztajn. But there are likely state-by-state differences, depending on the state-specific health care system and the characteristics of the local Latin-American communities, she said.

There are limitations to this work, including that the authors had no information on patient treatment preference or provider recommendations, according to Dr. Lichtensztajn.