Sociodemographic disparities found in non-treatment for prostate cancer

"It really is up to [investigators] and policymakers to determine why this is occurring in a clinical setting and what can be done to mitigate this," says Madison Novosel, BA.

In this interview, Madison Novosel, BA, discusses findings from her thesis project, “Associations between patient sociodemographic factors and non-treatment for localized prostate cancer”, which were presented at the 2023 American Society of Clinical Oncology Genitourinary Cancers Symposium in San Francisco, California. Novosel is an MPH student at the Yale School of Public Health in New Haven, Connecticut.

Could you describe the background of this study?

We decided to look at those who are getting treatment for prostate cancer vs those who are not getting treated. The key reason is because [for] those with low-risk prostate cancer, now there's evidence that active surveillance can be a treatment option, so they might not even need [treatment]. There are other studies that show quality of life might be [affected]. Since a lot of low-risk prostate cancers are diagnosed later, there are other competing causes of death or more quality of life [impacts].

We stratified the analysis by risk, and really, the main focus of the analysis was to look at those who [have] high-risk cancer. We defined our risk categories by [prostate-specific antigen] values, Gleason scores, and clinical stage. We were looking at who is not getting treated among the high-risk patients, and we used the National Cancer Database to do this. We looked at sociodemographic factors in the analysis, because there are some significant historical sociodemographic disparities, so we wanted to see if those persisted among the high-risk patient groups.

What were some of the notable findings? Were any of those surprising to you and your coauthors?

There are 2 main parts of the study. We looked at trends over time, and then again, as I mentioned, the risk stratification. For the trends over time, the low-risk groups increased in non-treatment over time, which is expected, especially with the increasing uptake of active surveillance as a treatment option. The intermediate risk [group] increased slightly, [which was] also expected. But the high-risk [group] did not change, which was a little bit surprising, because we expected [that] if you have high-risk cancer, you're going to want to get treatment. It did not change over time, so we were surprised that we didn't see a decrease. That was one thing that we found striking.

As far as risk stratification, we, again, were mostly focused on the high-risk groups. The Medicaid and uninsured patients had significantly lower odds of getting treatment than those who [have] private insurance. That was really striking. I believe our odds ratio was 0.4, which was extremely different with our large sample size. There's also differences in income quartiles. Those who are in the lowest income quartile were significantly less likely to get treatment than those who are in the 3 higher quartiles for income. We also saw in the high-risk group that patients who identified as Black were much more likely to not receive treatment than their White counterparts. That was a really striking result also.

What needs to be done to reduce the disparities that you mentioned?

The most striking one was the uninsured patients are way less likely to get treated. This could imply a more upstream policy intervention is needed, [because] the private insurance groups were our baseline. There definitely needs to be a look at the insurance structure in the United States. With Medicaid, it's the same thing.

Is any further research on this topic planned? If so, what might that focus on?

We're going to do a very similar analysis using the updated 2020 dataset. We were using the 2018 data for this analysis. We're going to take it a step further and look at interactions between insurance groups and race categories to see if this disparity is exacerbated by the combined effect that they have on each other.

What is the take-home message for practicing urologists?

The biggest message is that these disparities are present. They're present as far as racial and ethnic groups, socioeconomic status, and insurance status, so it is up to [investigators] and policymakers to determine why this is occurring in a clinical setting and what can be done to mitigate this, [such as] looking at more systemic roots of why these disparities are occurring and then implementing policies to mitigate this.

Reference

1. Novosel M, Smani S, Marks VA, et al. Associations between patient sociodemographic factors and non-treatment for localized prostate cancer. J Clin Oncol. 2023;41(suppl 6):307. doi:10.1200/JCO.2023.41.6_suppl.307