The racial disparities in prostate cancer (PCa) are among the largest in all of cancer diagnoses, with Black men presenting at a younger age with more advance PCa and increased mortality compared to White men. Although lack of proper screening and underutilization of healthcare resources in the Black community are well studied, it has been long thought that genetic and biologic predispositions to PCa are the main reasons why Black men have worse outcomes. A recent study by Dess et al1 seemed to debunk this theory, as they found no differences between Black and White men in prostate cancer-specific mortality after controlling for quality, access to healthcare and standardized treatment. This provides strong evidence that more emphasis should be placed on correcting the healthcare disparities in PCa rather than focusing on race itself.
Multiparametric magnetic resonance imaging (mpMRI)-ultrasound fusion biopsy (FBx) of the prostate is increasingly being utilized for the evaluation of men with clinical suspicion of PCa. FBx has been found to increase the detection of clinically significant cancer while decreasing the detection of clinically insignificant cancer compared to the standard 12-core systematic biopsy.2 There is an anticipation of movement towards FBx as a standard of care for PCa diagnosis and further evaluation on the implications of this are needed.
To our knowledge, our study is the first to investigate racial variation in the utilization of FBx.3 We found that Black men were 68% less likely to receive an FBx compared to White men after controlling for factors such as age, prostate-specific antigen (PSA) level, abnormal digital rectal exam (DRE), family history of PCa, and health insurance provider. Further subgroup analysis stratified by prior biopsy history found that Black race remained a statistically significant negative predictor in biopsy-naïve patients (OR: 0.36, 95% CI: 0.20-0.64, P < 0.001), while Black men with a prior negative biopsy were less likely to receive FBx, although not statistically significant (OR: 0.51, 95% CI: 0.19-1.36, P = 0.179).
Our study provides evidence that the racial disparities in PCa extend into the type of prostate biopsy used for the initial evaluation of PCa. While our study controlled for the clinical predictors and the insurance status, the uncontrolled sociodemographic factors and/or the implicit bias by physicians could have contributed to this discrepancy in the biopsy-naïve cohort. In October 2019, the American Urological Association updated the standard operating procedure of mpMRI, stating that sufficient data now exists to support the recommendation of mpMRI prior to biopsy for all men under consideration for prostate biopsy, without a previous history of biopsy.4 It remains to be seen how this change will impact the disparities in prostate cancer evaluation vis-à-vis fusion biopsy utilization.Written by: Connor Hoge, BS, and Abhinav Sidana, MD, Department of Urology, University of Cincinnati College of Medicine, Cincinnati, Ohio
References:
- Dess, Robert T., Holly E. Hartman, Brandon A. Mahal, Payal D. Soni, William C. Jackson, Matthew R. Cooperberg, Christopher L. Amling et al. "Association of black race with prostate cancer–specific and other-cause mortality." JAMA oncology 5, no. 7 (2019): 975-983.
- Sidana, Abhinav, Matthew J. Watson, Arvin K. George, Ardeshir R. Rastinehad, Srinivas Vourganti, Soroush Rais-Bahrami, Akhil Muthigi et al. "Fusion prostate biopsy outperforms 12-core systematic prostate biopsy in patients with prior negative systematic biopsy: a multi-institutional analysis." In Urologic Oncology: Seminars and Original Investigations, vol. 36, no. 7, pp. 341-e1. Elsevier, 2018.
- Hoge, Connor, Sadhna Verma, Daniel J. Lama, Ilana Bergelson, Monzer Haj-Hamed, Sean Maynor, Krishnanath Gaitonde, and Abhinav Sidana. "Racial disparity in the utilization of multiparametric MRI–ultrasound fusion biopsy for the detection of prostate cancer." Prostate Cancer and Prostatic Diseases (2020): 1-6.
- Bjurlin, Marc A., Peter R. Carroll, Scott Eggener, Pat F. Fulgham, Daniel J. Margolis, Peter A. Pinto, Andrew B. Rosenkrantz et al. "Update of the Standard Operating Procedure on the Use of Multiparametric Magnetic Resonance Imaging for the Diagnosis, Staging and Management of Prostate Cancer." The Journal of Urology (2019): 10-1097.