Last year’s lockdown during the early days of the coronavirus pandemic erased cancer surgery from many hospitals’ calendars as they diverted resources to meet the mounting surge in Covid-19 patients. A new study reports a wide racial disparity in which men with prostate cancer during the pandemic’s first wave underwent a prostatectomy, a gap that was tightly tied to where they received cancer care.
Before the pandemic, there was little difference between Black and white men in their rates of receiving the surgery, considered the standard of care for prostate cancer patients whose cancer had not spread and who were at intermediate to high risk. From mid-March to mid-May 2019, about 18% of Black men and 19% of white men had the procedure to remove the prostate gland. A year later, only 1% of Black men had a prostatectomy, while 26% of white patients did during those two months of lockdown.
It’s generally accepted that prostatectomy can be delayed for six months to a year, so the men who waited were not harmed, the researchers wrote in their paper, published Thursday in JAMA Oncology. But the disparity between who had the surgery dovetails with a history of inequities in cancer care. In general, Black people have a 20% higher rate of dying from cancer than white people, and studies have concluded social determinants as well as health system inequities — not biological factors — are to blame for the difference.
Searching for reasons to explain why hospital restrictions early in the pandemic resulted in unequal treatment, the researchers found that hospitals with more Black patients were more likely to pause prostate cancer surgery altogether.
“I think it’s an important study and it shows what happens when our system is under pressure,” said Nathan Berger, a medical oncologist and professor at Case Western Reserve University School of Medicine in Cleveland who was not involved in the study. “It’s very much a systemic problem. ‘Systemic racism’ has a negative connotation, but I do think this is systemic. In this case, it’s because the systems were different and different people were there.”
Covid-19 has disproportionately affected Black people, and its devastating impact is widening other disparities in care, the authors said. The gap they discovered in prostate surgery was dramatic.
“We were surprised by the degree of the disparity,” said Adrien Bernstein, a senior urologic oncology fellow at Fox Chase Cancer Center in Philadelphia and a study co-author. “We are hoping to shed light on the inequities that can occur and on how fragile our health care system is. When it’s stressed, we see where those fractures are.”
Bernstein and her colleagues analyzed a database of 647 patients — 269 patients during the pandemic and 378 from before the pandemic — with untreated, nonmetastatic prostate cancer who had similar risk factors and prognoses. Patients received their care from the Pennsylvania Urologic Regional Collaborative, which represents 11 groups and 127 urologists practicing at academic medical centers and community clinics in both urban and rural areas.
Black men were significantly less likely than white men to have a prostatectomy. Rates of the surgery fell for all men from March to May 2020, but they dropped 91% for Black men and only 17% for white men. After that first pandemic surge, rates of surgery returned to about equal levels for Black and white men. Other races or ethnicities were not analyzed for this paper because of their small numbers.
“I think the important thing to note here is that no one really needed to be treated for prostate cancer, but there was a dramatic difference in the way that this care was being delivered,” said Andres Correa, assistant professor of urologic oncology at Fox Chase Cancer Center and a study co-author. “Disparities in care when these restrictions were put in place were affecting one part of the population more than others. When something like Covid hits, it just amplifies those disparities even more.”
From the beginning of the pandemic, hospitals in areas like New York City, where more people of color live, were swamped by Covid cases, and have had to pivot away from routine cancer care. Philadelphia was harder hit by Covid-19 cases in the first wave than the surrounding region, creating a different impact on hospitals in the city than outside. While 43% of Pennsylvania’s Black population lives in Philadelphia, only 6% of the state’s white residents do.
It’s possible that people with more resources could travel to hospitals still offering prostate cancer surgery, but the researchers did not track those patterns.
“These men were being told that they should have treatment and then they had to wait,” Bernstein said. “It’s really important to note that all these patients have diagnoses of prostate cancer. They’re tapped into the medical system. They already had a cancer diagnosis, and so these are the patients that have the resources to begin with.”
Understanding what happens to patients who are uninsured or underinsured will be important for narrowing the cancer outcomes gap, Bernstein said, in the midst of a pandemic or not.
“Unequivocally, the differential burden of the Covid-19 pandemic extends beyond the illness caused by contracting this virus,” Randy Vince Jr., a urologist at the University of Michigan, wrote in an editorial published with the study. “The existing pandemic highlights many of the inequities in our society rooted in a history of systemic racism and oppression.”
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