Prostate Cancer Awareness Month: Overcoming Disparities With Waqas Haque, MD, MPH

Waqas Haque, MD, MPH: Hi, everybody. I’m a first-year Medical Oncology Fellow at the University of Chicago. Today I’ll be talking briefly about some of the disparities that we see across prostate cancer. If you think about some of the disparities across cancer, there are a lot of different ones that you’re going to see. Specifically in prostate cancer, you see that African American men are 60% more likely to get prostate cancer than White men and that the death rate is more than double as per the latest report from the American Cancer Society.

But even looking beyond race, even things like ZIP code can affect your cancer risk. We find that men who are from poorer areas are 31% more likely to be diagnosed with advanced prostate cancer. Thinking about why that might happen is because early detection is crucial for prostate cancer, but not everybody has access to screening. And we also see that men who are uninsured are only half as likely to get tested for prostate-specific antigen (PSA) compared to someone who has insurance. And of course, being diagnosed much later, when the cancer is much harder to treat, leads to worse outcomes and worse survival, right?

Even after diagnosis, not all men will receive the same level of care. It was actually found that African American men are 21% less likely to receive definitive treatment compared to White men with similar cancer characteristics. This gap persists even when you account for things like age and overall health status.

But one of the really interesting things beyond this, even looking at the fact that from detection to diagnosis to treatment, looking beyond those disparities, is that there was a multiple cohort study of 300,000 patients with the prostate cancer, which found that Black race was not associated with inferior prostate cancer­–specific mortality and cohorts for randomized control trials that were sponsored by the VA Health System and by the National Cancer Institute, whereas it was associated with increased prostate cancer mortality within the SEER database.

What this is basically telling us is that when you look at stuff that’s going on in real-world data, of course these disparities are there, but if you actually give Black men similar access to care and standardized treatment, then Black men with non-metastatic prostate cancer have stage-for-stage prostate cancer mortality that’s comparable to that for White men. Basically what that’s telling us is that if you try to work in equity and access, we can actually get rid of some of these disparities and we have data to show that.

Beyond just generally improving access to care, what specific things can we do with prostate cancer to improve outcomes and improve equity? The first thing that we can really think about is choice of therapy, right? Of course, we’ve been treating prostate cancer for a long time and we have a lot of drugs that have very well-established long-term safety profiles.

Given the large number of men who have prostate cancer that’s hormone-sensitive and given the prolonged duration of therapy, I think both patients and payers tend to benefit from therapies that are cheaper and also effective in the long-term, and specifically using abiraterone instead of only using androgen receptor blockers, which could sometimes cost hundreds of thousands of dollars per year.

And of course, abiraterone went off patent in 2018, which means that more generic versions are now available, and there’s also some discussion about off-label dosing and different ways to adjust the dose with low-fat meals that provide similar efficacy. So thinking about dose adjustments to help reduce the cost can be something that oncologists work on.

And as I mentioned before, these therapies have a long duration of treatment, and you don’t just think about financial toxicity for these patients, you think about time toxicity, all the appointments, scheduling scans, having to talk to a provider, getting care from loved ones, things of that nature.

Another aspect we can work on to improve time toxicity is looking at how to modify stereotactic body radiation. It can be delivered in various time frames from once a week to the more commonly used every other day schedule, which completes your treatment within two weeks. When you use that schedule, you actually cut down your treatment duration by 50% to 75% compared to longer treatment courses. I think in the United States, going with bundled payment than billing per fraction can actually incentivize shorter treatment courses, which would lead to great number of patients who could be treated while reducing the resource use per patients. So once again, it’s sort of improving our overall resource utilization within the larger health system.

So just reviewing what we talked about today, we mentioned that there are disparities in prostate cancer in terms of race when it comes to detection, when it comes to screening, when it comes to diagnosis, and when it comes to treatment, but also that these things can be mitigated with sufficient access to care, and also that there’s specific strategies that we can use such as prioritizing use of abiraterone and also modifying the dosing for radiation to minimize the time and financial toxicity that patients have to undergo. Thanks for listening.

About Dr. Haque

Waqas Haque, MD, MPH, is a Hematology/Oncology Fellow at the University of Chicago. He recently completed his Internal Medicine Residency at New York University (NYU) in a Clinical Investigator Track. Dr. Haque has balanced his patient care work with a variety of research projects. During his fellowship training at the University of Chicago, he plans to further his work in innovative clinical trial design, value-based care delivery to cancer patients, and clinical investigation. He is a recipient of the 40 Under 40 in Cancer Award, which recognizes the contributions of rising stars and emerging leaders across the field of oncology.