Access to Prostate Cancer Care and Implications for Survival Among Minorities

In this issue of The Journal Miller et al (page 579) present evidence that the national trend during the last 2 decades of a significantly increased proportion of men being diagnosed with localized, low risk prostate cancer does not appear to apply to low income, uninsured men. Those men have a higher proportion of metastatic disease at diagnosis. Furthermore, among those economically disadvantaged men presenting with nonmetastatic disease at diagnosis Miller et al found no increase in the number with low risk disease (prostate specific antigen [PSA] less than 10 ng/ml, Gleason score less than 7 and clinical T stage less than T2). These findings did not change when the researchers stratified the sample of 570 men enrolled in the California IMPACT (Improving Access, Counseling and Treatment for Californians with Prostate Cancer) program by race and ethnicity. IMPACT, which started in 2001, provides free and comprehensive prostate cancer treatment to uninsured men in California with incomes of 200% or below the federal poverty level.1, 2

The results of this study by Miller et al indicate that the prevalence of metastatic disease at prostate cancer diagnosis in this impoverished population is 19%. In contrast the prevalence of distant disease in men with incident prostate cancer in the SEER (Surveillance, Epidemiology, and End Results) registries from 2000 through 2006 was 4%.3 Therefore, men diagnosed with prostate cancer who live in poverty are more likely to die of their disease than those with a higher socioeconomic status. As Miller et al point out this conclusion leads to an understanding of the need for comprehensive programs aimed at reducing or eliminating socioeconomic disparities in prostate cancer mortality.

However, we must address more than socioeconomic disparities in prostate cancer care. Although the majority of people living in poverty in the United States are white the population attributable risk of being poor for African-Americans is 3 times that of the white population.4 African-Americans have a disproportionately high rate of poverty with some 25% living below the federal poverty level compared to 8% of the white population in that category.4 This racial disparity in combination with the socioeconomic disparity already discussed places African-American men diagnosed with prostate cancer at an even greater risk of presenting with incurable disease.

The increase in the proportion of men in the broader United States population diagnosed with organ confined, low risk prostate cancer occurred during the same period as the widespread use of PSA screening.5 In this same period we witnessed a decrease in prostate specific mortality.6 These facts have led some experts to argue that early diagnosis with PSA screening combined with aggressive treatment results in decreased prostate cancer specific mortality.

Unfortunately the jury is still out on this question as we eagerly await the results of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial in the United States7 and the European Randomized Study of Screening for Prostate Cancer trial in Europe.8 If PSA screening is shown to decrease prostate cancer specific mortality, then clearly any comprehensive prostate cancer care program aimed at low income and minority populations should include screening and treatment to be effective.

However, the unequal burden of incurable prostate cancer borne by poor and minority populations will not be addressed by PSA screening alone even if it is proven to be associated with decreased cancer specific mortality. Nor are we dealing with a matter of prostate cancer related health alone. The problem highlighted by Miller et al is a general one that was outlined in the Institute of Medicine report on health disparities that despite the improvement in the overall health of the United States population during the last several decades, racial and ethnic minorities continue to have the highest rates of morbidity and mortality across an extremely broad range of diseases.9 For example, African-Americans have the highest rates of mortality from heart disease, cancer, stroke and HIV/AIDS, whereas Hispanics are nearly twice as likely as nonHispanics to die of diabetes.

A lack of access to health care undoubtedly has an important role in maintaining these health disparities. African-Americans, Hispanics, Asian-Americans, and other racial and ethnic minority populations are less likely than whites to have health insurance. The same lack of health insurance pertains to any low income population. Moreover, if these populations have insurance they have more difficulty obtaining health care and fewer choices in terms of where to obtain care.

Miller et al are correct to point out that the problem confronting economically disadvantaged and, we should add, minority populations is not over diagnosis and over treatment, but rather under detection and under treatment. Improving access to the preventive and treatment aspects of health care will go a long way toward reducing the disparities in disease morbidity and mortality suffered by poor and minority communities.