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. 2024 Dec;27(4):765-775.
doi: 10.1038/s41391-024-00815-1. Epub 2024 Apr 2.

Emerging racial disparities among Medicare beneficiaries and Veterans with metastatic castration-sensitive prostate cancer

Daniel J George  1 , Neeraj Agarwal  2 , Krishnan Ramaswamy  3 , Zachary Klaassen  4 , Rhonda L Bitting  5   6 , David Russell  3 , Rickard Sandin  7 , Birol Emir  3 , Hongbo Yang  8 , Wei Song  8 , Yilu Lin  9 , Agnes Hong  3   10 , Wei Gao  8 , Stephen J Freedland  11   12
Affiliations

Emerging racial disparities among Medicare beneficiaries and Veterans with metastatic castration-sensitive prostate cancer

Daniel J George et al. Prostate Cancer Prostatic Dis. 2024 Dec.

Abstract

Background: Previous studies have shown that Black men receive worse prostate cancer care than White men. This has not been explored in metastatic castration-sensitive prostate cancer (mCSPC) in the current treatment era.

Methods: We evaluated treatment intensification (TI) and overall survival (OS) in Medicare (2015-2018) and Veterans Health Administration (VHA; 2015-2019) patients with mCSPC, classifying first-line mCSPC treatment as androgen deprivation therapy (ADT) + novel hormonal therapy; ADT + docetaxel; ADT + first-generation nonsteroidal antiandrogen; or ADT alone.

Results: We analyzed 2226 Black and 16,071 White Medicare, and 1020 Black and 2364 White VHA patients. TI was significantly lower for Black vs White Medicare patients overall (adjusted odds ratio [OR] 0.68; 95% confidence interval [CI] 0.58-0.81) and without Medicaid (adjusted OR 0.70; 95% CI 0.57-0.87). Medicaid patients had less TI irrespective of race. OS was worse for Black vs White Medicare patients overall (adjusted hazard ratio [HR] 1.20; 95% CI 1.09-1.31) and without Medicaid (adjusted HR 1.13; 95% CI 1.01-1.27). OS was worse in Medicaid vs without Medicaid, with no significant OS difference between races. TI was significantly lower for Black vs White VHA patients (adjusted OR 0.75; 95% CI 0.61-0.92), with no significant OS difference between races.

Conclusions: Guideline-recommended TI was low for all patients with mCSPC, with less TI in Black patients in both Medicare and the VHA. Black race was associated with worse OS in Medicare but not the VHA. Medicaid patients had less TI and worse OS than those without Medicaid, suggesting poverty and race are associated with care and outcomes.

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Conflict of interest statement

DJG reports other from American Association for Cancer Research; grants and personal fees from Astellas Pharma Inc.; personal fees from AstraZeneca; personal fees from Axess Oncology; grants, personal fees, and non-financial support from Bayer H/C Pharmaceuticals; grants and personal fees from BMS; grants from Calithera; grants from Capio Biosciences; grants from EMD Serono; grants, personal fees, and non-financial support from Exelixis Inc; personal fees from Flatiron; grants and personal fees from Janssen Pharmaceuticals; personal fees from Merck, Sharp & Dohme; personal fees from Michael J Hennessey Assoc; personal fees from Millennium Medical Publishing; personal fees from Myovant Sciences Inc.; personal fees from NCI Genitourinary; grants and personal fees from Novartis; personal fees from Physician Education Resource; personal fees from Propella Therapeutics; grants and personal fees from Pfizer Inc.; personal fees from RevHealth; grants, personal fees, and non-financial support from Sanofi; personal fees from Seattle Genetics; personal fees from UroGPO; personal fees and non-financial support from UroToday; personal fees from WebMD; personal fees from Xcures. NA reports no personal conflicts of interest since April 15, 2021; lifetime conflicts of interest include consultancy to Astellas Pharma Inc., Astra Zeneca, Aveo, Bayer, Bristol Myers Squibb, Calithera, Clovis, Eisai, Eli Lilly, EMD Serono, Exelixis, Foundation Medicine, Genentech, Gilead, Janssen, Merck, MEI Pharma, Nektar, Novartis, Pfizer Inc., Pharmacyclics, and Seattle Genetics; research funding to institution from Arnivas, Astellas Pharma Inc., Astra Zeneca, Bavarian Nordic, Bayer, Bristol Myers Squibb, Calithera, Celldex, Clovis, Crispr, Eisai, Eli Lilly, EMD Serono, Exelixis, Genentech, Gilead, Glaxo Smith Kline, Immunomedics, Janssen, Lava, Medivation, Merck, Nektar, Neoleukin, New Link Genetics, Novartis, Oric, Pfizer Inc., Prometheus, Rexahn, Roche, Sanofi, Seattle Genetics, Takeda, and Tracon. KR, DR, and RS own stocks or stock options and are employees of Pfizer Inc., a study sponsor. ZK reports serving on advisory boards for Bayer, Astellas Pharma Inc., Myovant, and Pfizer; consulting to Sesen Bio; and serving on a speakers’ bureau for Lantheus. RLB reports no disclosures. BE is an employee of Pfizer Inc., a study sponsor. HY, WS, and WG are employees of Analysis Group, which was a paid consultant to the sponsors in connection with the development of this manuscript. YL is co-owner of BRAVO4HEALTH LLC. AH is an employee of Pfizer Inc., a study sponsor; was an employee of Astellas Pharma Inc., a study sponsor, at the time of the study; and owns stock in Veru, Revance, and Insmed. SJF reports consulting to Pfizer Inc., Astellas Pharma Inc., Janssen, Dendreon, Sanofi, Myovant, Merck, AstraZeneca, Clovis, and Bayer. No other disclosures were reported.

Figures

Fig. 1
Fig. 1. First-line treatment for mCSPC over time by race.
A First-line treatment for mCSPC over time by race in Medicare. B First-line treatment for mCSPC over time by race in the VHA. ADT androgen deprivation therapy, mCSPC metastatic castration-sensitive prostate cancer, NHT novel hormonal therapy, NSAA nonsteroidal antiandrogen, VHA Veterans Health Administration.
Fig. 2
Fig. 2. OS among patients with mCSPC by race.
A OS among patients with mCSPC by race in Medicare. B OS among patients with mCSPC by race in the VHA. CI confidence interval, mCSPC metastatic castration-sensitive prostate cancer, OS overall survival, VHA Veterans Health Administration.
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