Paul Nguyen: Hello, everybody. It's great to have you all with us today for this UroToday recording. It's a special video presentation of an important paper that recently came out. I'm Dr. Paul Nguyen, I'm Professor of Radiation Oncology at Harvard Medical School and a Radiation Oncologist at Dana-Farber Brigham Cancer Center in Boston, Massachusetts.


And we're very excited today to be discussing the topic of health equity in prostate cancer, which is such an important issue. And we're excited to have two authors who have shined a light on this quite remarkably. So Bhav Jain is the first author. And what's remarkable is that he is an undergraduate at MIT. He is in his junior year right now, and really excited to have young folks like him contributing to the field in this way.


And the senior author on this paper is Dr. Christopher Dee, who is an intern at Memorial Sloan Kettering, and will be a resident in radiation oncology there. And they're going to be talking about racial disparities in treatment delay among younger men with prostate cancer. So, Bhav, do you want to take it away?


Bhav Jain: Absolutely. Thank you so much for that excellent intro, Dr. Nguyen, and I'm extremely excited to share our new paper entitled Racial disparities in treatment delay among younger men with prostate cancer.

This was actually recently published in prostate cancer and prosthetic diseases earlier this year and is in affiliation with MIT MSK and also Brigham Women's Hospital. So for overarching context, over the past four to five decades, we've seen the incidents of prostate cancer increasing quite rapidly among the AYA or the adolescent and young adult patient population. As you can see here on this graph from 1925 up until the modern-day, the relative incidence of prostate cancer, the rate of that increase has vastly outpaced other common cancer sites and is now at approximately 0.4 per a hundred thousand patients for those under the age of 40. And moreover, now over 10% of new prostate cancer diagnoses occur in men under the age of 55.


So this is kind of an increasingly common issue. And we're also observing that more and more younger men are also experiencing treatment delay due to various factors, including barriers to actually access to care and also concerns with the adverse impacts of various modes of treatment, as well as other specific demands which occur at this age, mostly involving families, as well as the possible impacts of financial toxicity.


So because of this issue, we felt that it might be important to actually examine the patterns of treatment delay in an effort to actually highlight those populations of patients who may stand to benefit from greater efforts to both promote adherence to timely treatment, as well as instill efforts at the insurance and also provider level to decrease overarching barriers to accessing care. And the aim of the study was basically inspired by recent evidence showing that there are in fact, fairly substantial consequences associated with the delay of treatment for patients with localized prostate cancer beyond six months including for example, substantially increased risk of biochemical recurrence.


And we also felt that the influence of race as a broader social construct might be important to study as well, influencing this delay. So as such, we used the National Cancer Database or the NCDB to identify racial disparities associated with the treatment delay among younger men. So men under the age of 55 with localized prostate cancer. And in particular, we hypothesized that both age and race may in fact, interact to produce especially accentuate disparities for young Black patients when compared to either older Black patients or White prostate cancer patient populations. So more specifically in terms of the methods of this paper as mentioned, we used the National Cancer Database, and we identified men aged less than 64 years old, who were diagnosed with localized, intermediate, or high/very high-risk prostate cancer based on the National Comprehensive Cancer Network Guidelines.


And we used or employed multi-variable logistic regression in order to actually evaluate various, both socioeconomic and also clinical predictors of the experience of delay in either surgery, radiation, or other modes of therapy, specifically marking it as a treatment delay if the patient experienced it more than 180 days or six months following their initial diagnosis. And we employed standardly used predictors, including the year of the initial diagnosis, the age group, the race, insurance status, education, income, and other aspects as well. And in specific, I want to emphasize that we had the age effectively stratified by either 18 to 55 or 56 to 64 because evidence does suggest that under 55 is kind of the adolescent or young adult age group. And as mentioned earlier, we attempted to specifically analyze age groups across race inter-fractions in order to assess if there were any specific impacts happening among the young Black versus the older Black patient population. In terms of the results, our multi-variable logistic regression actually found that Black men are experiencing treatment delays more frequently than White men.


But more specifically, we also found that although younger age is a protective effect for White men, in the sense that young White men are not experiencing treatment delays at any increased rate over older White men, we actually found that same age impact was not protective for Black men. So specifically young Black men were experiencing treatment delays more often than older Black men. And we also found that these trends persist upon restricting the example to entirely young men or to men who had either insurance or managed care options, which implies that there are in fact barriers that underscore this outside of the standard cost of care.


What this ultimately shows is that Black men with localized prostate cancer are experiencing treatment delays at least twice as often as White men. And this is accentuated among the younger Black men patient population, as well as I mentioned, those who either have insurance or managed care. This is especially notable given that earlier evidence has shown Black men are at increased risk of presenting with either distant metastases or just more broadly have higher incidence. They also tend to, unfortunately, receive less guideline-concordant care and are also almost three times as likely to die from prostate cancer over White men.


And we also more broadly hypothesized that the aforementioned disparities are driven by structural barriers, such as the differential ability to either take time off of work or pay for the various indirect costs of patient care as well as broader injustices impacting minority patient populations and the need for improved workforce diversity. So now I'd be more than happy to answer other specific questions about how we, for example, may improve these disparities more broadly in the long run as well. Thank you.

Paul Nguyen: Well, thank you, Bhav. And Chris, that was fantastic. I think it's such an important issue, and we know that Black men present with prostate cancer at 1.6 times greater rate than White men, but die at 2.4 times greater rate. And we have seen a lot of the structural barriers that there are to care, including Black men getting less guideline-concordant care, Black men getting more delays in treatment. And I think what you two have identified here is something new, which is that younger Black men in particular are having longer delays. Whereas, younger White men actually have fewer delays. They're getting treatment in a slightly more timely fashion, whereas younger Black men are having a sort of a more disproportionately delayed therapy. So this is a new thing I haven't heard before. So, what could be the role of financial toxicity in explaining these findings? We hear a lot about financial toxicity these days.

Bhav Jain: Absolutely. I'll start with that one. So I think the general sentiment is that younger patients may in general experience disproportionately more adverse impacts from financial toxicity in part, because they, for example, haven't had enough time to actually amass these think levels of either resources or economic capital. And that impacts their ability to actually pay for the different treatment options that they're offered. Especially if we examine the fact that all of these, or specifically that our results even persisted among men who were insured, right? So even if you examine men who are above the financial line for either ACA or Medicaid, we're still seeing that, either because of the highly imposed copays that these patients have, or because of the actual cost of supporting their families and loved ones that they end up experiencing delays and also possibly experiencing less adherence to these specific courses of treatment as well.

Christopher Dee: Absolutely. And I'm happy to build upon what Bhav discussed. And when we think of financial toxicity in the context of patients who are receiving care for cancer, especially prostate cancer is the idea of direct as well as indirect costs of care. In adjusting for patients who have insurance, we try to control for patients who have some help with regard to paying for the direct cost of care, but that doesn't account for the indirect cost of care that many patients face. The racial disparity that we're seeing and underscoring that race is itself a social construct, tells us that there is an interaction between someone's race and their financial reserves and the barriers that may make manifest when we examine the indirect cost of care.

What are some of these indirect costs of care? Things that range from parking to taking time off work, to childcare, to the opportunity cost of missed days of work, all that can impact the patient's ability to seek timely care. And the data show that there may be medical consequences for that kind of delay, which I think is another aspect of structural racism and barriers to care that our minoritized patients face.


Paul Nguyen: That's great. And I know we've seen a lot of great work from Dr. Fumiko Chino at Memorial Sloan Kettering on financial toxicity. And so, one of the things you found is that even when you adjust for insurance, I think this effect still persists. So what should we do as providers or insurance companies, what should be done to fix this?

Bhav Jain: Absolutely. So I think one of the more effective kinds of interventions we've seen for example, at the provider level are offering the option for physician, patient racial concordance. And what this means is that if you have a Black patient who presents with localized prostate cancer, offering them the option to, for example, receive or seek care from a Black doctor. This has been seen or shown to actually improve the adherence as well as build more kind of understanding between the doctor and the patient. More broadly, though, on kind of an educational level, I think there certainly needs to be increased efforts to ensure that we are offering options for cultural competency and cultural humility for doctors such that they understand a bit more acutely the needs and challenges that patients face, especially patients who as we just now discussed, might be experiencing the adverse impacts of financial toxicity at this age.

I'll just mention one more at the insurance level. I kind of alluded to earlier, even if patients are above the financial eligibility for either ACA or Medicaid, they might have private insurance, but this insurance might not be of the highest quality. And that actually might result in patients having disproportionately higher copays even for the most basic courses of treatment. And so at the insurance level, there needs to be a shift more onto emphasizing that we will have patients pay for outcomes actually for the value achieved, as opposed to simply each individual service that is ultimately rendered.

Christopher Dee: I think building off of what Bhav said, as well, as providers, I think it's important for us to pay attention to the potential causes of delays that patients face. A lot of these are things that may not necessarily be apparent to us the first interview or something that they might hesitate to tell us when we first meet them. The causes that have been cited in the literature are quite varied and definitely vary based on each patient's individual experience. These can range from as discussed the financial toxicity of direct and indirect costs of care, but also things such as the historical injustices that have been perpetrated against minoritized patients that may lead them to be less trustful of the medical system.

A lot of the onus falls on us to one, help mitigate structural barriers and structural inequities that impact patient's ability to seek timely care, but also to make amends for the system's injustices that were carried out upon minoritized patients. I think a lot of that played out that the individual level may be the most effective ways to encourage timely access to care for our most vulnerable patients.

Paul Nguyen: Yeah. And hitting on what you just said about trust. I mean, what do we know about trust in the healthcare system and treatment receipt?

Bhav Jain: Yeah, I can start. I think when we think of the historical atrocities experiments such as the Tuskegee Syphilis study among others, there's a deep history of Black patients specifically being used as experimental subjects for treatments that may or may not work, largely to the benefit of white or majority patient populations. And I think that trust is very deeply kind of ingrained even now. Even specifically in the oncology space, the story, for example, of Henrietta Lacks and how kind of her stem cells were ultimately used even against her either informed consent or knowledge. I think all of these examples are so deeply ingrained in many patients' minds every time they see a doctor. And that I think ultimately impacts their interest or ability to seek care in an appropriate manner. And so I think that is a major aspect.

And I think that's why more broadly, we need to ensure that doctors at the individual level are ingraining improved trust, are ensuring that their patients feel as knowledgeable and as comfortable as possible. It's not enough to simply administer a treatment. We have to ensure that patients are aware of exactly why is this specific treatment being administered, right. And what are the both short and long-term impacts of that?

Christopher Dee: Building off of Bhav's points as well is I think the onus falls on us as a medical community to actually work to earn that trust. I think a lot of that can happen in the consultation room where we show patients through our words and through our actions that we care. I think a lot of that may play a role in decreasing the effect of historical injustices and helping patients realize that the physician in front of them does care and is working hard to gain their trust. I think that can go hand in hand with the work that we can do to understand what the barriers are that individual patients face. From my experience, even as a resident, a lot of it is about making patients feel that they are heard and so much of that listening to their concerns and addressing their concerns, I think can play a huge role in terms of improving adherence to treatment through the whole course of the cancer continuum.

Paul Nguyen: Great. So perhaps in the last minute here, what's next for your research on this?

Bhav Jain: I think the main aspect I'm most interested by is the opportunity to actually kind of venture out into the field, and see the impact of many of these possible interventions. Is it the case that, for example, improving transportation from patients' homes straight to the hospital actually improves adherence? Is it the case that over say a decade or so of sustained and informed educational opportunities for medical students that we're actually seeing improved cultural competency being employed with Black and other minority patients. And I think actually kind of assessing the impacts of these specific options and specific interventions, both at the insurance and also the provider level are most appealing to me. And certainly an aspect I'll be involved in as a future medical student.

Christopher Dee: I want to add to that as well. And reiterate that multiple studies have shown that there are different points of adherence where we found that minoritized patients are at a disadvantage. We've shown that in terms of treatment delay, as in this paper. We've shown in a separate paper, the disparities that minoritized patients face with regard to treatment, to getting treatment at all, as well as the completion of treatment in the setting of radiation for prostate cancer. I think, we've shown all of these through the National Cancer Database, which unfortunately does not get at the reasons, the underlying reasons for why patients face these disparities in the first place. I think a lot of the work that needs to be carried out in the future is in the realm of qualitative work, where we actually go into the community and partner with these patients and ask them why, what are the barriers that they face, and what are the potential levers that we can manipulate to help them, to improve adherence to care, but also to decrease the barriers that these patients who want to get better are facing.

Paul Nguyen: Great. Bhav and Chris, thank you so much for your great work and for spending time with us today to tell us more about it. Keep up the great work.

Christopher Dee: Thank you for the opportunity.

Bhav Jain: Very much appreciate it.