Disparities in GU Cancers Recognized, but Slow to Change

More than 400,000 new cases of genitourinary (GU) cancers were expected to occur in the United States in 2022,¹ with prostate, bladder, and kidney cancers accounting for a substantial portion of cancer incidence and mortality overall.² Although work has been done in recent decades to increase screening and significantly decrease mortality from these cancers, disparities persist across racial and ethnic groups, sex, geographic location, and socioeconomic status.^2–4

“Each cancer type has its own constellation of demographic differences, disparities, and barriers to care,” said Nirmish Singla, MD, MSc, director of translational research in GU oncology and associate professor of urology and oncology in the Brady Urological Institute at Johns Hopkins University.

GU Oncology Now recently spoke with clinicians about some of the disparities that exist, why they persist, and what might be done to correct them.

Commonly Known Disparities

“The first thing that comes to mind when I think of disparities in GU cancers is related to [Black] men and prostate cancer,” said Christine Ibilibor, MD, MSc, an assistant professor in the Division of Urologic Oncology at the University of Virginia. “[Black men] have higher rates of death from prostate cancer, as well as more aggressive disease, with early diagnosis of locally advanced or metastatic disease.”

Prostate cancer is the most commonly diagnosed cancer in Black men and the second leading cause of cancer death. Black men are estimated to have more than twice the risk for death from prostate cancer compared with White men and are diagnosed at younger ages.⁵

In the bladder cancer realm, men in the United States have a four-fold higher incidence compared with women.⁶ However, Dr. Ibilibor noted that women can experience longer delays in diagnosis compared with men.

“Women are more likely, even in the presence of gross hematuria—a common symptom and side effect of bladder cancer—to have symptoms attributed to a benign cause,” Dr. Ibilibor said. “Whereas men are more likely to be evaluated for malignancy.”

A retrospective evaluation showed that women had significantly longer time from initial hematuria claim to bladder cancer claim and that a greater proportion of women compared with men had delays longer than 6 months in bladder cancer diagnosis. Women were more than twice as likely to be diagnosed with a urinary tract infection and were about 20% less likely to have abdominal or pelvic imaging performed.⁷

Delays in bladder cancer diagnosis have been independently linked to female gender, as well as Black race and uninsured status,⁸ and Black patients and women appear to have worse survival outcomes.^9,10

For certain types of kidney cancer, Black race has also been associated with worse overall survival compared with White patients, even though Black patients tend to present with lower-stage disease—an indication that other factors are at play.^11,12

“A less commonly discussed disparity exists within testicular cancer, a type of cancer that tends to affect younger men,” Dr. Singla said.

Studies of contemporary trends indicate that men aged 25 to 29 years experience higher rates of mortality and metastatic incidence.¹³

“We are also finding a rapid increase in testicular cancer diagnoses among Hispanic men,” Dr. Singla said. “They tend to be diagnosed at an earlier age—a median of 5 years younger than their Caucasian counterparts—and also have more aggressive disease features at diagnosis.”^14,15

Geographic Disparities

Geographic disparities exist within cancers as a whole, and within GU cancers specifically. Data from the National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results Program database indicated higher incidence of bladder cancer among White individuals in the Appalachia region and higher incidence rates of bladder cancer in parts of the South.¹⁶

Another investigation of rural-urban trends found that rural patients and non-Hispanic Black patients had shorter survival across all cancer types; 5-year survival probabilities for rural patients with lung, prostate, breast, and colorectal cancers were consistently lower than those for urban patients.¹⁷

“One thing that tends to be particularly important for GU cancers is seeking care at experienced, high-volume centers,” Dr. Singla said. “That is something that patients in more rural settings may not be able to easily access.”

Within bladder cancer specifically, it has been shown that multidisciplinary providers are key to optimizing outcomes, Dr. Singla said.

“The problem is that high-volume centers tend to be centralized, and that can be challenging for patients who live over 50 miles out from a centralized region,” he noted. “They may have inadequate access to the care they need.”¹⁸

Access to high-volume centers may be challenging, but patients may also lack access to any kind of specialty practice for GU cancers. Data from the American Urological Association (AUA) show that only a minority of practicing urologists have primary practice locations in nonmetropolitan areas, with 12.0% of urologists aged older than 65 years and only 6.3% of those aged younger than 45 years in these areas. Put into numbers, of the 13,976 practicing urologists included in the AUA data, 62 practice in rural areas and 224 in small towns compared with 12,576 in metropolitan areas.¹⁹

Socioeconomically vulnerable subgroups also appear to have worse GU cancer outcomes. One recent study looking at county-level age-adjusted mortality rates for populations with GU cancer showed that those living in the lowest socioeconomically ranked counties had worse overall GU cancer-related mortality and worse death rates for prostate cancer and renal cell carcinoma. Subgroups of non-Hispanic Black and Hispanic patients with prostate cancer in these counties had significantly higher overall mortality.⁴

Another study by Dr. Singla and colleagues found that patients with germ cell tumors treated at safety net hospitals were more likely to be uninsured, present to the emergency department, and have metastatic disease.¹⁵

Within oncology, workforce shortage is also a dilemma, explained Rana R. McKay, MD, an associate clinical professor at the University of California, San Diego.

“This limits access to clinicians, particularly in rural and vulnerable areas,” Dr. McKay said.

Dr. McKay discussed a 2006 study commissioned by the American Society of Clinical Oncology (ASCO) to evaluate the expected supply of and demand for oncology services through 2020. Demand for oncology services was expected to increase by almost 50% from 2005 to 2020, but with an associated increase in providers of only 14%. This would translate to a shortage of between 9.4 and 15.0 million visits or 2550 to 4080 oncologists.²⁰

Other Contributing Factors

Access to care is not the only issue contributing to disparities.

“Health care policies, including prior authorization, oncology drug pricing, and others have impacted access,” Dr. McKay said. “Limited access to clinical trials and drug shortages have also plagued oncology.”

Dr. Ibilibor has studied disparities in access to clinical trials in Black men with prostate cancer.²¹ As an example, in a landmark study investigating androgen deprivation therapy plus docetaxel for prostate cancer, only 9% of participants were Black or non-White men.²² This failure to adequately include Black men limits the broad applicability or generalizability of any result.

Although certain patient-related barriers to trial participation exist, such as preexisting conditions, limited health insurance coverage, or lack of awareness of trials, there are several provider-related factors that could be addressed as well, Dr. Ibilibor and colleagues found.

Clinicians are often gatekeepers to trial participation and can be influenced by personal biases and attitudes, which may impede the initiation of conversations about clinical trial participation. These biases can include assumptions about whether a person might want to participate based on where they live, their age, or their race/ethnicity. Availability of clinical trial sites is also sometimes limited within rural areas or predominantly Black or Hispanic communities.

“There is often not a whole lot of partnership between academia and communities that have historically been excluded,” Dr. Ibilibor said. She noted the NCI Community Oncology Research Program (NCORP) is currently looking into expanding to have recruitment sites for NCI-based trials in communities that would typically fall outside the catchment area of large academic institutions.

The US Food and Drug Administration has also released a guideline, “Enhancing the Diversity of Clinical Trial Populations—Eligibility Criteria, Enrollment Practices, and Trial Designs,” that has 4 recommendations designed to broaden inclusion, including thinking about diversity of participants during the trial design process and improving practices for recruiting diverse participants to the trial.²³

In order to improve access to clinical trials, screening, and care for GU cancers, cultural and language barriers also may need to be addressed.

“There are cultural sensitivity variables among men with prostate cancer,” Dr. McKay said as an example. “Culture can impact an individual’s beliefs, values, customs, and ways of thinking and communicating.”

One qualitative study about prostate cancer among self-identified Black and Latino adult men and women found that many believed that lifestyle was a risk factor for prostate cancer, including links with sexual activity. Interviews revealed lack of trust in the health care system, concerns about the cost of screening or treatment, and desire for gender-concordant care.²⁴

Dr. Singla has found that certain patients are very much interested in the integration of complementary or alternative medicines as a reflection of cultural beliefs.

“There can sometimes be a disconnect between what the provider thinks is best and what the patient believes,” Dr. Singla said. It is important not to be dismissive of these beliefs and work to find a middle ground.

Workforce Diversity

To further address disparities it is critically important to expand the GU oncology workforce to be culturally diverse and ensure discussions are culturally sensitive, Dr. McKay said.

“It takes a multifaceted team approach to tackle this issue,” she emphasized.

Data from the AUA estimated that only 11.6% of practicing urologists are women, about 5.0% are of Hispanic ethnicity, and only about 2.0% are African American/Black, with little growth in this last demographic over the last decade.¹⁵ Data on diversity specific to the GU oncology workforce are scarce, but ASCO estimated that about 2.3% of practicing oncologists self-identify as Black and 5.8% self-identify as Hispanic; close to one-third are women.²⁵

“I can attest that many times patients from certain backgrounds are better able to relate to providers who share their same background,” Dr. Singla said. That may be related to race/ethnicity, language, religion, or cultural connections, he continued, adding “that the inherent connection of shared experience can be very important.”

Data back up the importance of a shared background. A study of surgical outcomes showed that sex discordance between surgeons and patients negatively affected outcomes after common procedures.²⁶ Other studies have shown that gender or racial/ethnic concordance are linked with improved patient experience scores,²⁷ positive impacts on uptake of cancer screening,²⁸ and decreased health care expenditutes.²⁹

A large part of increasing diversity in the workforce is increasing diversity in the pipeline, and trends in racial/ethnic distribution for pipeline academic urologists show that there may be an issue. There were no changes in the proportion of Hispanic urology applicants and a decrease in the proportion of Black urology applicants from 2007-2008 to 2019-2020.³⁰

One study using an anonymous survey of 353 applicants to the University of Texas Southwestern, Dallas, for the 2020 AUA Residency Match found that females as compared with males and underrepresented minority (URM) students as compared with non-URM students were twice as likely to note discrimination.³¹ Additionally, both females and URM students noted that higher proportions of female or URM residents, faculty, and leadership within a program favorably impacted rank lists.

“I would say that diversity is increasing and that the AUA has made a big push for diversity, equity, and inclusion among providers,” Dr. Singla said.

In a statement on physician workforce planning, the AUA acknowledged “a need to enhance underrepresented minority representation in medical schools and in the physician workforce as a means to ultimately improve access to care for minority and underserved groups.”

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