Androgen deprivation therapy (ADT) is a standard of care in the treatment of metastatic prostate cancer. We have known about disparities in prostate cancer treatment for some time, but I was taken aback by the data presented by Benjamin et al at the 2022 Genitourinary Cancers Symposium (abstract 22). Patients with newly diagnosed metastatic (stage IV) prostate cancer were identified through the California Cancer Registry, and, according to the data, approximately 23% of these patients were not getting ADT of any sort. The rates of receiving ADT were a bit higher in men from the highest socioeconomic status group, but, even then, only 77.3% received ADT. Thus, if the data are accurate, we still have a lot of work to do.

Disparities in outcomes according to race and ethnicity, as well as the potential for biological factors to account, in some part, for observed disparities, have been controversial for at least 30 years. We published an analysis on black race as an adverse prognostic factor for prostate cancer recurrence following radical prostatectomy in an equal-access health care setting years ago, and it was a hot-button issue even back then.  

This year, Recio-Boiles and colleagues reported that, even after accounting for socioeconomic disparities, Mexican men present with a more aggressive disease compared with non-Hispanic white men and other Hispanic American subgroups (abstract 23). They adjusted for age, prostate-specific antigen, year of diagnosis, stage, insurance, income, education, and performance score, and they found that those who were identified as Mexican still had higher odds of initial metastatic presentation and lower odds of receiving treatment compared with non-Hispanic white men, whereas no statistically significant differences were observed for the other Hispanic American subgroups. 

Data presented at the conference speaking to the disparate impact of the COVID-19 pandemic on African American men were, unfortunately, consistent with my experience. In abstract 29, Lee et al analyzed data from veterans from January 2019 through June 2021. Regardless of race, the rates of prostate-specific antigen screening decreased immediately after January 2020, but the magnitude of the reduction in biopsies and cancer diagnoses was approximately 5 times larger among black men than white men. They observed a large disparity even in an equal-access health care system. We have made similar observations here at Duke, where we serve a county that is approximately 50% African American.

I think that the bottom line on racial and ethnic disparities in prostate cancer is that they are definitely multifactorial and are influenced by access to care, insurance status, mistrust of the health care system, and many other factors. And still, it is possible that there could be some type of biological basis in play on top of all of that. 

The divide between academic and community settings can also be a source of disparity. Gajra et al explored this issue with community oncologists who were invited to attend a virtual meeting on the VISION trial data (abstract 120). Most of the community oncologists found the VISION trial data of lutetium-177–prostate-specific membrane antigen–617 (¹⁷⁷Lu-PSMA-617) in metastatic castration-resistant prostate cancer to be compelling and indicated that they are likely to incorporate it into their treatment regimens, if approved by the US Food and Drug Administration (FDA).* If nearly 25% of patients in California are not even getting ADT, access to treatments such as ¹⁷⁷Lu-PSMA-617 is sure to be a challenge. Costs and other barriers are really going to make this difficult, just like with almost every other treatment for prostate cancer. 

Finally, Vehawn and colleagues focused on urban vs rural disparities in abstract 25. They reported that people living in rural settings who had relatives in urban areas actually had a better chance of getting state-of-the-art treatment. This made sense to me, and it is something that I have seen in my own family. I come from a humble upbringing, and I have been blessed to do well and to work at this major medical center. Over the years, I have been able to bring many of my relatives who live in rural areas to Duke to get care that they might not have had access to locally. 

*Addendum: On March 23, 2022, subsequent to this interview, the FDA approved lutetium Lu 177 vipivotide tetraxetan (formerly referred to as ¹⁷⁷Lu-PSMA-617) for the treatment of progressive PSMA-positive mCRPC. The FDA also approved a complementary gallium-68–based agent indicated for PET of PSMA-positive lesions.