Prostate cancer screening in Black men in Canada: a case for risk-stratified care

The rural disadvantage - prostate cancer outcomes of rural and urban patients over 25 years

PURPOSE

Prostate cancer is a common malignancy among men, with disparities based on the geographic location. This study aims to evaluate long-term trends in prostate cancer outcomes among rural and urban populations within a universal health care system, providing insights into the persistent disparities in cancer-specific mortality despite supposed equal access to medical coverage.

METHODS

A retrospective cohort study was conducted using data from the Alberta Cancer Registry (January 1, 1999 to December 31, 2022) and the Alberta Prostate Cancer Research Initiative (APCaRI) (July 1, 2014 to June 7, 2024). There were 45,602,119 person-years from the Alberta Cancer Registry and 8932 men from APCaRI. The exposure was the place of residence, categorized as urban or rural, based on postal codes at the time of diagnosis and death. The primary outcome was prostate cancer-specific mortality.

FINDINGS

Rural men were diagnosed at an older age (66.7 vs. 68.9, p<0.001) and had higher age-adjusted prostate cancer-specific mortality compared to urban men (52.0 vs. 37.6 deaths per 100,000, p<0.001). Though both groups showed improvements over time, rural areas consistently had higher age-adjusted mortality rates. Despite a 38% relative increase in prostate cancer specific mortality, rural patients had minimal, though statistically significant differences in PSA (9% vs. 11% >20, p = 0.008), stage (40% vs. 46% T2-T4, p<0.001) and Gleason Grade Group (11% vs. 14% ≥4, p<0.001) at diagnosis.

CONCLUSIONS

The study reveals that rural men experienced significantly worse prostate cancer outcomes compared to urban men. These findings highlight the need for targeted health care interventions to improve access to care in rural areas.

Navigating prostate cancer screening in Canada for marginalized men through PSA screening and guidelines adherence A call to action for policymakers

Prostate cancer remains a notable public health concern. Prostate-specific antigen (PSA) testing plays a role in screening for prostate cancer. Black and Indigenous men are disproportionately impacted by prostate cancer. Moreover, men from these populations also face other challenges related to the social determinants of health. These challenges can make it difficult for these men to access screening services. Innovative approaches, such as free, universal screening, mobile screening, engaging communities may help improve prostate cancer screening for these populations.

Prostate Cancer Among Black Men in Canada

Importance

Prostate cancer is a prevalent disease among men worldwide, exhibiting substantial heterogeneity in presentation and outcomes influenced by various factors, including race and ethnicity. Disparities in incidence, stage at diagnosis, and survival rates have been observed between Black men and those of other races and ethnicities.

Objective

To compare prostate cancer outcomes between Black men and men with other race (Asian, Hispanic, Indigenous, Middle Eastern, White, Multiracial, and Other) in a universal health care system, with race and ethnicity self-reported.

Design, Setting, and Participants

This was a prospective, observational cohort study of men diagnosed with prostate cancer between June 1, 2014, and August 28, 2023, who self-identified race and ethnicity. Participants included men who had been prospectively enrolled in the Alberta Prostate Cancer Research Initiative from the 2 major urology referral centers in Alberta (University of Alberta and University of Calgary). All men with prostate cancer enrolled in the initiative were included.

Exposure

Race and ethnicity.

Main Outcomes and Measures

The primary outcome was the stage and grade of prostate cancer at diagnosis. Further outcomes included age and prostate-specific antigen level at diagnosis, initial treatment modality, time from diagnosis to initial treatment, and prostate cancer-specific, metastasis-free, and overall survivals.

Results

A total of 6534 men were included; 177 (2.7%) were Black, and 6357 (97.3%) had another race or ethnicity. Men who identified as Black were diagnosed with prostate cancer at an earlier age (mean [SD], 62.0 [8.2] compared with 64.6 [7.7] years; P < .001) and had a lower Charlson Comorbidity Index rating (14% compared with 7% ≤ 1; P < .001) compared with men of other races. Men who identified as Black had similar prostate-specific antigen levels at diagnosis, TNM category (74% vs 74% with T1-T2; P = .83) and Gleason Grade Group (34% compared with 35% Gleason Grade Group 1; P = .63). Black men had similar rates of prostate cancer-specific (hazard ratio [HR], 1.10; 95% CI, 0.41-2.97; P = .85), metastasis-free (HR, 0.88; 95% CI, 0.42-1.46; P = .44), and overall (HR, 0.55; 95% CI, 0.25-1.24; P = .15) survival.

Conclusions and Relevance

The findings of this cohort study suggest that Black men, despite being diagnosed at a younger age, experience comparable prostate cancer outcomes compared with men of other races.

Racial discrimination in healthcare services among Black individuals in Canada as a major threat for public health: its association with COVID-19 vaccine mistrust and uptake, conspiracy beliefs, depression, anxiety, stress, and community resilience

OBJECTIVES

To examine the prevalence of major racial discrimination (MRD) in healthcare services and its association with COVID-19 vaccine mistrust and uptake, conspiracy theories, COVID-19-related stressors, community resilience, anxiety, depression, and stress symptoms.

STUDY DESIGN

The study used a population-based cross-sectional design.

METHODS

Data from the BlackVax dataset on COVID-19 vaccination in Black individuals in Canada was analyzed (n = 2002, 51.66% women). Logistic regression analyses were performed to examine the association between MRD and independent variables.

RESULTS

32.55% of participants declared having experienced MRD in healthcare services. Participants with MRD were less vaccinated against COVID-19, presented higher scores of vaccine mistrust, conspiracy beliefs, COVID-19 related stressors, depression, anxiety, and stress, and had lower scores of community resilience. They were more likely to experience depression (AOR = 2.13, P < 0.001), anxiety (AOR = 2.00, P < 0.001), and stress symptoms (AOR = 2.15, P < 0.001). Participants who experienced MRD were more likely to be unvaccinated (AOR = 1.35, P = 0.009).

CONCLUSIONS

Racial discrimination experienced by Black individuals in health services is a major public health concern and threat to population health in Canada. Federal, provincial, and municipal public health agencies should adapt their programs, strategies, tools, and campaigns to address the mistrust created by racial discrimination.

Recommandations pour des soins préventifs pour promouvoir l’équité en matière de santé

Contexte:

Malgré des investissements importants dans un système de soins de santé public qui comprend des services préventifs, on continue d’observer des disparités évitables en matière de santé au Canada. L’équipe avait pour objectif de formuler des recommandations pour des soins de santé préventifs qui puissent améliorer l’équité en matière de santé par la priorisation des interventions efficaces à l’intention des groupes défavorisés.

Méthodes:

La ligne directrice a été élaborée par un comité composé de spécialistes en soins primaires et de membres de la patientèle, avec la contribution d’un groupe de patientes-et patientspartenaires ayant vécu diverses expériences. Après avoir sélectionné les sujets à prioriser, nous avons recensé les revues systématiques, les essais randomisés et contrôlés récents sur les méthodes de dépistage et d’autres études pertinentes sur l’efficacité du dépistage et de la prise en charge. Nous avons utilisé l’approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation) pour formuler les recommandations et avons suivi le guide AGREE II (Appraisal of Guidelines for Research and Evaluation) pour rédiger le rapport. Il en a été de même avec les principes du Guidelines International Network pour la gestion des intérêts concurrents. Les recommandations ont été passées en revue par un comité externe d’experts en contenu avant d’être distribuées à des intervenants à l’échelle nationale pour approbation.

Recommandations:

Nous avons formulé 15 recommandations concernant le dépistage et d’autres soins préventifs et 1 recommandation de nature politique visant à améliorer l’accès aux soins primaires. Ainsi, nous recommandons de prioriser une stratégie de communication pour le dépistage du cancer colorectal à partir de l’âge de 45 ans et pour l’évaluation du risque de maladie cardiovasculaire pour lutter contre les iniquités en matière de santé et promouvoir la santé. Les interventions particulières qui devraient être déployées pour lutter contre les iniquités comprennent l’autodépistage du virus du papillome humain (VPH) et du VIH, et le test de libération de l’interféron γ pour l’infection tuberculeuse. Le dépistage de la dépression, de la toxicomanie, de la violence conjugale et de la pauvreté devrait également permettre aux personnes touchées d’accéder plus facilement à des interventions éprouvées. Nous recommandons une prise de contact systématique avec des professionnels de la santé en soins primaires pour les personnes défavorisées.

Interprétation:

Les interventions préventives éprouvées peuvent aider à combattre les iniquités en matière de santé si la priorité est accordée aux personnes défavorisées. Les médecins, les organisations de santé et les gouvernements devraient adopter des mesures fondées sur des données probantes et en faire le suivi s’ils veulent promouvoir l’équité en matière de santé partout au Canada.

Preventive care recommendations to promote health equity

BACKGROUND

Avoidable disparities in health outcomes persist in Canada despite substantial investments in a publicly funded health care system that includes preventive services. Our objective was to provide preventive care recommendations that promote health equity by prioritizing effective interventions for people experiencing disadvantages.

METHODS

The guideline was developed by a primary care provider-patient panel, with input from a patient-partner panel with diverse lived experiences. After selecting priority topics, we searched for systematic reviews and recent randomized controlled trials of screening and other relevant studies of screening accuracy and management efficacy. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to develop recommendations and followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) reporting guidance. We managed competing interests using the Guideline International Network principles. The recommendations were externally reviewed by content experts and circulated for endorsement by national stakeholders.

RECOMMENDATIONS

We developed 15 screening and other preventive care recommendations and 1 policy recommendation on improving access to primary care. We recommend prioritized outreach for colorectal cancer screening starting at age 45 years and for cardiovascular disease risk assessment, to help address inequities and promote health. Specific interventions that should be rolled out in ways that address inequities include human papillomavirus (HPV) self-testing, HIV self-testing and interferon-γ release assays for tuberculosis infection. Screening for depression, substance use, intimate partner violence and poverty should help connect people experiencing specific disadvantages with proven interventions. We recommend automatic connection to primary care for people experiencing disadvantages.

INTERPRETATION

Proven preventive care interventions can address health inequities if people experiencing disadvantages are prioritized. Clinicians, health care organizations and governments should take evidence-based actions and track progress in promoting health equity across Canada.