The findings illustrate the need to better understand and reduce any biases in physician decision-making, as well as other potential sources of disparities when identifying and clinically managing prostate cancer, according to a team led by Nino Abashidze, PhD, from the University of Wyoming and colleagues.
The authors note that MRI is playing a more important role in helping to diagnose prostate cancer. Traditionally, men are screened for prostate cancer by prostate-specific antigen (PSA) tests, and those with elevated PSA results undergo prostate biopsy. But systematic nontargeted biopsies miss clinically meaningful prostate cancer and overdiagnose insignificant prostate cancer, the researchers stated.
Recently, prostate MRI has emerged as a way to evaluate men with elevated PSA before possible prostate biopsy, and its use is increasing nationally. Prostate MRI may identify suspicious regions in the prostate to target for subsequent biopsy, significantly increasing the likelihood of identifying clinically meaningful prostate cancer. Additionally, a prostate MRI scan may obviate the need for biopsy, decreasing overdiagnosis of insignificant prostate cancer, the researchers wrote.
But consensus is lacking regarding the use of MRI in the initial detection of prostate cancer, and accepted guidelines are not available. This lack of standardization likely fosters both variation and disparities in prostate MRI utilization, the investigators said.
Indeed, previous research has uncovered racial disparities in multiple aspects of the diagnosis and treatment of prostate cancer. For example, Black and Hispanic patients are significantly less likely than white patients to undergo PSA screening. For the current study, the researchers investigated if those disparities extended into the workup of men found to have elevated PSA levels, particularly using MRI.
"Using a large administrative data set that included both health insurance claims and laboratory results, we observed evidence of significant racial and ethnic disparities in the use of prostate MRI after PSA testing that widens with higher PSA results," the researchers wrote.
The cohort study involved an analysis of 794,809 insured men from the U.S. and was based on deidentified medical claims from January 2011 to December 2017. The investigators determined that Black, Hispanic, and Asian patients were consistently less likely to receive prostate MRI scans within 180 days after their PSA test date. Compared with white patients, Black patients with PSA levels above 4 ng/mL and 10 ng/mL were 24.1% and 35% less likely to undergo subsequent prostate MRI, respectively.
In addition, Hispanics with PSA levels greater than 10 ng/mL were 23% less likely than white patients, and Asian patients with PSA levels greater than 4 ng/mL were 24% less likely than white patients to have a prostate MRI scan.
From an age perspective, the researchers found that Black patients between the ages of 40 and 54 with a PSA above 4 ng/mL were 39.8% less likely to undergo a prostate MRI than white patients. Among patients 65 to 74 years old, Black patients with PSA levels above 4 ng/mL and 10 ng/mL were 23.6% and 43.9% less likely to receive a prostate MRI than white patients, respectively.
Asian patients between the ages of 55 and 64 with a PSA above 2.5 ng/mL and 4 ng/mL were 57.3% and 62.9% less likely to receive a subsequent prostate MRI than white patients. Compared to white patients, Hispanic patients between the ages of 55 and 64 with a PSA above 10 ng/mL were 67.6% less likely to receive a subsequent prostate MRI, according to the investigators.
Interestingly, the racial and ethnic disparities observed in the study were statistically insignificant among patients over the age of 75. This is a population for which the U.S. Preventive Services Task Force does not recommend screening for prostate cancer, noted senior author Danny Hughes, PhD, of the Georgia Institute of Technology.
Significant differences between whites and Black, Hispanic, and Asian patients were found in other age groups, but not for those ages 75 or older.
"This indicates the important role that clearly defined guidelines can play in addressing racial and ethnic disparities in care. For the age groups for which prostate cancer screening is recommended, clearer guidelines are still needed for the optimal use of prostate MRI," Hughes said.
Besides a lack of clear guidelines on the use of prostate MRI following PSA testing, both unconscious and conscious biases may play a role in healthcare inequity. Previous research has shown that physicians are less likely to discuss treatment options and potential side effects with Black patients than with white patients.
The investigators believe that more research is required to assess the role of decision-making biases among physicians for observed racial and ethnic disparities in the use of prostate MRI and if these disparities extend to the use of prostate biopsy.
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