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Original Investigation
March 3, 2022

Mediators of Racial Disparity in the Use of Prostate Magnetic Resonance Imaging Among Patients With Prostate Cancer

Author Affiliations
  • 1Department of Urology, Yale School of Medicine, New Haven, Connecticut
  • 2Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
  • 3Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut
  • 4Department of Urology, University of California, San Francisco, San Francisco
  • 5Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
  • 6Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
JAMA Oncol. 2022;8(5):687-696. doi:10.1001/jamaoncol.2021.8116
Key Points

Question  What factors underlie racial disparity in the use of prostate magnetic resonance imaging (MRI) among Black and White patients with prostate cancer?

Findings  This population-based cohort study of 39 534 Medicare beneficiaries found that Black patients with prostate cancer were less likely than White patients to receive a prostate MRI. Mediation analysis revealed that geographic differences, socioeconomic status, and racialized residential segregation were associated with most of the Black vs White racial disparity in prostate MRI use.

Meaning  This study suggests that efforts to address racial disparity in the use of prostate MRI should address upstream factors, including socioeconomic status, geographic variation in practice, and structural racism.

Abstract

Importance  Racial disparity in the use of prostate magnetic resonance imaging (MRI) presents obstacles to closing gaps in prostate cancer diagnosis, treatment, and outcome.

Objective  To identify clinical, sociodemographic, and structural processes underlying racial disparity in the use of prostate MRI among men with a new diagnosis of prostate cancer.

Design, Setting, and Participants  This population-based cohort study used mediation analysis to assess claims in the US Surveillance, Epidemiology, and End Results (SEER)–Medicare database for prostate MRI among 39 534 patients with a diagnosis of localized prostate cancer from January 1, 2011, to December 31, 2015. Statistical analysis was performed from April 1, 2020, to September 1, 2021.

Exposure  Diagnosis of prostate cancer.

Main Outcomes and Measures  Claims for prostate MRI within 6 months before or after diagnosis of prostate cancer were assessed. Candidate clinical and sociodemographic meditators were identified based on their association with both race and prostate MRI, including the Index of Concentration at the Extremes (ICE), as specified to measure racialized residential segregation. Mediation analysis was performed using nonlinear multiple additive regression trees models to estimate the direct and indirect effects of mediators.

Results  A total of 39 534 eligible male patients (3979 Black patients [10.1%] and 32 585 White patients [82.4%]; mean [SD] age, 72.8 [5.3] years) were identified. Black patients with prostate cancer were less likely than White patients to receive a prostate MRI (6.3% vs 9.9%; unadjusted odds ratio, 0.62, 95% CI, 0.54-0.70). Approximately 24% (95% CI, 14%-32%) of the racial disparity in prostate MRI use between Black and White patients was attributable to geographic differences (SEER registry), 19% (95% CI, 11%-28%) was attributable to neighborhood-level socioeconomic status (residence in a high-poverty area), 19% (95% CI, 10%-29%) was attributable to racialized residential segregation (ICE quintile), and 11% (95% CI, 7%-16%) was attributable to a marker of individual-level socioeconomic status (dual eligibility for Medicare and Medicaid). Clinical and pathologic factors were not significant mediators. In this model, the identified mediators accounted for 81% (95% CI, 64%-98%) of the observed racial disparity in prostate MRI use between Black and White patients.

Conclusions and Relevance  In this this population-based cohort study of US adults, mediation analysis revealed that sociodemographic factors and manifestations of structural racism, including poverty and residential segregation, explained most of the racial disparity in the use of prostate MRI among older Black and White men with prostate cancer. These findings can be applied to develop targeted strategies to improve cancer care equity.

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