Secondary Care Gap Tied to Racial Disparities in Prostate Cancer Mortality
Key Insights
An observational study of over 83,000 Medicare beneficiaries found Black and white men with localized prostate cancer (search) received secondary treatment at similar rates after initial surgery or radiation.
Among patients who did not receive secondary treatment, Black men faced up to twice the risk of prostate cancer (search)-specific death compared to white men.
The findings, published in JAMA Network Open, suggest disparities in follow-up surveillance and timely detection of recurrence may drive unequal outcomes rather than differences in treatment rates alone.
A large observational study published July 21 in JAMA Network Open has uncovered a critical gap in prostate cancer (search) care: among patients who did not receive secondary treatment after initial therapy, Black men faced up to two times higher risk of dying from prostate cancer than their white counterparts, despite both groups receiving secondary care at similar rates.
The study, which analyzed data from 83,156 Medicare beneficiaries aged 66 and older diagnosed with localized prostate cancer (search) between 2004 and 2017, is the first to examine how receipt of secondary treatment may contribute to racial disparities in prostate cancer mortality.
"To our knowledge, this study is the first to examine how receiving secondary treatment may contribute to racial disparities in mortality among prostate cancer (search) patients," said first author Dr. Jessica Acolin, who conducted the research during postdoctoral training in psychiatry and behavioral sciences at the University of Washington School of Medicine (search). Acolin is now an affiliate assistant professor in health systems and population health at the UW School of Public Health.
Persistent disparities despite similar treatment rates
Black men are more than twice as likely as white men to die from prostate cancer (search) in the United States. To understand where disparities emerge after diagnosis and initial treatment, the researchers utilized the Surveillance, Epidemiology and End Results (SEER)-Medicare-linked database, which combines clinical information from population-based cancer registries with Medicare claims data.
The study population was divided into two cohorts based on primary treatment type: surgical removal of the prostate or radiation therapy. This methodological approach minimized underlying differences in cancer severity and comorbid conditions, as patients receiving similar treatments shared comparable clinical characteristics.
Secondary treatment — offered when cancer recurs after initial therapy — can include radiation, surgery, androgen-deprivation therapy (search), cryotherapy, chemotherapy, or high-intensity focused ultrasound, depending on the first-line approach.
Approximately 19% of surgery patients and 28% of radiation patients went on to receive secondary treatment, with no significant racial differences observed in either the likelihood of receiving such care or in survival outcomes after secondary treatment.
The mortality gap emerges in the absence of secondary care
The stark disparity surfaced among patients who did not receive secondary treatment. In this group, 1.85% of Black patients died from prostate cancer (search) — a rate more than double that of white patients.
In the surgical cohort, 19% of Black patients who did not receive secondary treatment died, compared with 13% of white patients. The gap was similarly pronounced in the radiation cohort, where 37% of Black patients without secondary treatment died versus 30% of white patients.
Because cancer characteristics — and consequently downstream outcomes — were expected to be similar between Black and white patients at the time of primary treatment, these findings raise significant concerns about disparities in who ultimately receives potentially beneficial secondary care.
Follow-up surveillance as a potential driver
The researchers hypothesize that differences in follow-up monitoring may explain the observed disparities. "Our guess would be that there's less follow-up surveillance among Black patients, because you need to be going in regularly to get the tests," Acolin said. "If they're not getting the tests as frequently, any recurrence might be caught later, which means that it might be past the point where additional treatment would be recommended because the cancer advanced too far."
The findings suggest that the overall rate of secondary treatment alone does not explain persistent racial disparities in prostate cancer (search) deaths. Instead, the unequal outcomes point to possible differences in access to care, quality of follow-up, timing of treatment, monitoring after initial therapy, or other social and structural factors. The researchers note that additional investigation is needed to determine the specific causes.
Implications for long-term survivorship care
Acolin emphasized that the findings carry an important message for patients and clinicians alike. "The takeaway, especially for Black men, is that the prostate cancer (search) treatment story doesn't end after first treatment. There are still lots of things that can happen afterwards, like quality of care and continued follow-up, that matter for long-term survival."
The research was overseen by co-author Dr. Ruth Etzioni, an affiliate professor of biostatistics at the UW School of Public Health and a biostatistician at Fred Hutch Cancer Center (search). Senior author Dr. Yaw Nyame is an assistant professor of urology at the UW School of Medicine and a faculty member at Fred Hutch Cancer Center.
The study was funded by grants from the Department of Defense (CDMRP W81XWH211053), the National Cancer Institute (P50 CA097186-17 and U01 CA253915), the Andy Hill CARE Fund (FY23-POP-02), and the National Institute on Alcohol Abuse and Alcoholism (T32AA007455).