Prostate cancer is prevalent and active surveillance is commonly used for low-risk patients. However, Black patients, compared to White patients are more likely to choose active surveillance and have a higher risk of cancer progression. Active surveillance poses challenges in detecting clinically significant cancer, especially anterior lesions. Magnetic resonance imaging (MRI) has shown promise in identifying prostate cancer. However, guidelines for MRI-guided biopsy (MRI-GB) utilization are inconsistent. A recent population-based analysis examined MRI-GB usage in the U.S. with a focus on racial differences before PCa diagnosis.
To conduct the study, researchers utilized SEER-Medicare data from January 2012 to December 2017 (J Clin Oncol 2023; doi: 10.1200/JCO.2023.41.16_suppl.5093). The cohort comprised individuals diagnosed with prostate cancer; however, those with incomplete data, diagnosed at death, enrolled in HMO, or lacking continuous coverage were excluded. CPT codes were used to identify prostate biopsy and MRI utilization. Multivariable logistic regression was employed to assess racial disparities in MRI utilization before prostate cancer diagnosis, controlling for various covariates such as age, race, SEER region, marital status, state buy-in for Medicare, education, income, Charlson comorbidity index, and procedure year.
Over the study period from 2012 to 2017, there was a significant increase in MRI utilization among 38,612 eligible individuals before prostate cancer diagnosis. Among White individuals, MRI use rose from 3.2 percent to 24.3 percent, while among Black patients it increased from 1.8 percent to 14.2 percent.
However, compared to White patients, Black individuals were 38 percent less likely to undergo MRI before PCa diagnosis, as indicated by an odds ratio (OR) of 0.62 (95% CI: 0.52-0.74). Factors such as state buy-in for Medicare (OR=0.44; 95% CI: 0.30-0.65) and geographic region (Central vs. West, OR=0.40; 95% CI: 0.34-0.45) were also strong predictors associated with lower MRI utilization, in addition to race.
Oncology Times reached out to senior study author, Stephen Freedland, MD, for his insights on the implications of their findings. He is Director of the Center for Integrated Research in Cancer and Lifestyle, Co-Director of the Cancer Genetics and Prevention Program, and Associate Director for Faculty Development at the Samuel Oschin Comprehensive Cancer Institute at Cedars-Sinai. He is also a faculty physician in the Division of Urology at the Cedars-Sinai Surgery Department.
Oncology Times: What are the potential clinical implications of missing anterior prostate cancer using the common method of transrectal ultrasound-guided biopsy, and how can MRI-GB address this concern more effectively?
Freedland: "MRI is a major step forward in prostate cancer detection. However, given limitations that it is not available everywhere with trained readers and continued pushback from some insurances, it is not yet used for all prostate biopsies. There are data to suggest that Black men may have more anterior located tumors. Note that not all data agree on that point and thus this remains a hypothesis. If true, the importance of this is that anterior tumors are harder to detect on traditional transrectal ultrasound guided biopsies, which has been the historical standard of care for men in the U.S. As such, using historical standards, we would hypothesize that Black men would be disadvantaged in having their cancers detected, leading to delayed detection and ultimately more aggressive disease at the time of diagnosis. Given that MRI stands the possibility to level the field and detect these cancers better, it is concerning that MRI use in Black men is lagging behind."
Oncology Times: What are the potential barriers hindering the adoption of MRI-GB for prostate cancer workups, and how can these barriers be addressed to ensure equitable access and utilization across different racial groups?
Freedland: "I am not aware of much research to understand these barriers, but I would posit two main barriers: provider knowledge/experience and insurance. Many providers who perform MRI-guided biopsies use software to allow them to fuse the MRI images with the ultrasound images obtained in the office. I would surmise that if a provider is not familiar with this software, cannot afford the software, or is uncomfortable using the software, they are highly unlikely to use MRI-guided biopsies.
"Another barrier is insurance. Historically, insurance companies did not pay for MRIs prior to biopsy. While this is much better, it is not universal. Thus, when you have a group of people who on average have lower socioeconomic status and thus perhaps less likely to have private insurance with full coverage for MRIs, this will create barriers. Though our analyses adjusted for zip-code level income and education, it remains unknown which exact social determinants of health that tract with race are driving these findings.
"Nonetheless, it remains concerning that Black men are disadvantaged in this way. To overcome this, in my opinion, would require two steps: 1) complete insurance coverage for MRI prior to biopsy, and 2) updated guidelines that state not that MRI is allowed, but MRI is strongly preferred/required when available. Until those changes occur, I am concerned we will continue to see certain groups disadvantaged, which will only increase prostate cancer health disparities."
Dibash Kumar Das is a contributing writer.