In certain settings, the practice of performing magnetic resonance imaging (MRI) scans of the prostate before a patient undergoes biopsy has led to less detection of less-aggressive tumors and better detection of significant tumors that do require treatment. And so, clinicians are increasingly using this screening modality because of these benefits. New data suggests, however, that there are disparities when it comes to who has access to this costlier, but more effective screening modality.
Data published online ahead of print in the journal Cancer shows that non-Hispanic Black men and men living in less urban areas were less likely to undergo prebiopsy MRI of the prostate compared with other groups (2021; doi.org/10.1002/cncr.33518). For the study, researchers used cancer registry data from the Surveillance, Epidemiology, and End Results (SEER) program linked to billing claims for fee-for-service Medicare beneficiaries who were men with nonmetastatic prostate cancer. Out of more than 50,700 men identified, 964 underwent prebiopsy MRI, 80 percent of whom lived in California, New Jersey, or Connecticut. The men undergoing prebiopsy MRI were more than three times as likely to be non-Hispanic White than non-Hispanic Black, and were nearly twice as likely to live in urban areas as rural areas.
The message for clinicians, study coauthor Christopher P. Filson, PhD, Assistant Professor in the Department of Urology at Emory University School of Medicine and Member of Winship Cancer Institute, told Oncology Times: "Primary care providers and urologists caring for men at risk for prostate cancer should understand the important role that prostate MRI can play in characterizing tumor grade at diagnosis. They should offer this testing and determine whether they have local resources to have it provided in a high-quality fashion."
1 What are the key findings from this study that weren't previously known?
"For decades, urologists relied on imperfect, non-targeted prostate biopsies to diagnose men with prostate cancer. More recently, the use of pre-biopsy prostate MRIs has emerged as a potential pathway to providing a more accurate picture of the aggressiveness of a prostate cancer patient's tumor at diagnosis through targeted biopsies. However, this technology can be costly and its initial adoption was limited to selected areas in the country. Those characteristics make the initial dissemination of prostate MRI particularly susceptible to disparate access for traditionally underserved populations, like persons of color and those in more rural areas.
"Our findings confirmed our suspicion that Black and Hispanic men with prostate cancer were less likely to undergo a prebiopsy MRI before their prostate cancer diagnosis. We also found men in more rural areas were less likely to receive this guideline-recommended imaging before their biopsy. Importantly, we showed that these differences were not related to initial adoption of prostate MRI being limited to areas with fewer Black and Hispanic men. In areas where prostate MRI was used more frequently, we found similar disparities based on patient race and ethnicity."
2 How does this one specific health inequity inform other health inequities and disparities?
"Our findings are just a start. They highlight that more work needs to be done to validate the persistence of these disparities among a larger and more contemporary sample of men. From there, there needs to be a more granular examination of the influence that access-related factors have on these observed disparities. Potential barriers to prostate MRI include impaired access to providers offering prostate MRI, access to health care in general related to insurance coverage, and ability to pay for expensive health care even with insurance coverage.
"The impact of prebiopsy MRI on downstream prostate cancer outcomes is still being assessed. Although the use of MRIs can improve detection of higher-grade cancers at the time of initial diagnosis, it still remains opaque whether a more accurate initial assessment of a higher-grade cancer results in patients living longer overall. As that [question] gets clarified with ongoing population-level research, we will have a better sense of the magnitude of impact that these disparities may have on cancer control among underserved populations."
3 Are there any interventions that might help address and reverse disparities?
"This is a great question, and it highlights the necessary shift we need to start seeing within disparities research. We need to start identifying interventions that would ameliorate these observed disparities. Such interventions may come in many forms, including community-based educational interventions, increasing the number of providers using prostate MRI, or decreasing the financial burden for novel diagnostic testing.
"It is also becoming more apparent that a 'one-size-fits-all' strategy to combat disparities in cancer care is unlikely to be successful. Ongoing research should focus on identifying optimal targets for any interventions that are developed. A lot of work remains.
"We will continue to work on characterizing potential barriers to the effective deployment of prostate MRI at a population level, and we are also working on characterizing the influence of the physician on whether a prostate MRI is utilized.
"I also hope to work on developing effective interventions to permit access to prostate MRI for those men who would derive the greatest benefit. We need to assess the financial impact associated with prostate MRI use for patients. These tests are not always covered by insurance, and even if they are, can require payments of hundreds of dollars, which some men cannot afford."