Prostate cancer is the most common malignancy among men worldwide and the second leading cause of cancer-related death in men, disproportionately affecting Afro-descendant populations.⁽¹⁾ Globally, over 1.4 million new cases of prostate cancer are diagnosed annually, with notable disparities in incidence and outcomes based on geographic, racial, and socioeconomic factors.⁽¹⁾ Brazil mirrors this trend, with approximately 70,000 new prostate cancer cases diagnosed each year.⁽²⁾ Afro-descendant patients, in particular, experience more aggressive forms of the disease and worse survival rates compared to white patients.⁽³⁾ These disparities are exacerbated by socioeconomic barriers that limit access to timely diagnosis and treatment, particularly in public healthcare systems.⁽⁴⁾

Studies conducted in the United States and Europe have shown that Black men are more likely to develop aggressive prostate cancer and are often diagnosed at later stages. Research also highlights that Black men face worse treatment outcomes and higher mortality rates than white men.⁽⁵⁾ This pattern is echoed in Brazil, where structural barriers in the public healthcare system delay diagnoses and result in suboptimal treatment, particularly for Afro-descendant populations.^(4,6)

Socioeconomic status further contributes to disparities in prostate cancer outcomes. Access to advanced diagnostic tools and treatments, such as prostate-specific antigen screening and robotic surgery, is often limited in public hospitals, exacerbating health inequities between different racial and socioeconomic groups.⁽⁷⁾

This study aimed to explore these disparities by comparing prostate cancer outcomes between Black and white patients treated in public and private healthcare settings in Brazil. The study focused on the outcomes of patients treated at Hospital Israelita Albert Einstein (HIAE), a leading private institution in South America, or at Hospital Municipal Vila Santa Catarina (HMVSC), a public hospital with a high patient volume.

To evaluate disparities in patients with prostate cancer treated at private and public health systems in Brazil.

A total of 2,387 patients aged 18 years or older diagnosed with prostate cancer were included in this study, with treatments administered at both systems between 2017 and 2024. In the cohort, 2,077 patients (87.1%) were younger than 75 years old, while 309 (12.95%) were older than 75. Racial demographics were reported by 58% of the patients, with 1,046 (75.41%) identifying as white, 192 (13.84%) as mixed-race, 102 (7.35%) as Black, 46 (3.32%) as Asian, and 1 (0.07%) as Indigenous.

Most patients (72.51%) were treated at private services, with the remaining 27.49% treated at public services. Distance to the treatment center was also a significant factor, as 61.48% of patients resided more than 10km from their respective treatment centers (Table 1).

Racial disparities play a central role in the unequal outcomes for patients with prostate cancer in Brazil. Black patients were significantly more likely to be diagnosed with metastatic disease compared to white patients, highlighting broader socioeconomic inequalities and healthcare access challenges. These disparities were especially pronounced in public hospitals, where Black patients often presented with advanced disease, resulting in poor prognoses and intensive treatment requirements. This finding aligns with other studies showing that inequalities in healthcare access led to delayed diagnoses, poor outcomes for minority groups, and are likely associated with higher costs.^(8-10)

An additional inequality was the impact of distance from treatment centers. Patients living more than 10km away from the hospital were 95% less likely to undergo robotic surgery, indicating that geographic barriers also play a role in access to advanced treatments. This is a crucial aspect that amplifies the disparities already caused by racial and socioeconomic factors.

The higher incidence of metastatic prostate cancer among Black patients directly correlated with long hospital stays and high treatment costs. Patients with metastatic disease require complex interventions, which may not be readily available in public hospitals, increasing the strain on the healthcare system. Prolonged hospitalizations not only elevate costs but also limit the availability of beds for other patients, exacerbating the burden on the healthcare system.

In addition, age and metastatic disease were significant factors for treatment and survival outcomes. Patients over 75 years old, as well as those diagnosed with metastasis, were less likely to receive robotic surgery and had poor survival rates. These findings reinforce the need to address both age-related and advanced disease challenges in the context of access to specialized treatments and are aligned with data from Brazilian patients published previously.^(9-11)

In contrast, patients treated at private hospitals benefit from early diagnoses and access to advanced treatments, such as robotic surgery, targeted therapy, and immunotherapy; none of which were available in the SUS, as shown in Table 1. These advanced treatments contribute to shorter hospital stays, lower treatment costs, and better overall outcomes than less modern treatment options. The availability of cutting-edge technologies at private institutions not only enhances clinical results but also significantly improves the quality of life for their patients.⁽¹²⁾

This study underscores the systemic barriers that contribute to poor outcomes for Black patients in public hospitals. Delayed diagnostic tests, limited access to specialized treatments, and socioeconomic challenges all contribute to higher metastatic disease rates at diagnosis for patients treated at public hospitals than those treated at private hospitals. Addressing these disparities requires expanding access to early screening programs and improving the availability of advanced therapies in public hospitals,⁽¹²⁾ which could help mitigate racial disparities in prostate cancer outcomes.^(13,14) Additionally, implementing targeted screening programs focused on Black men could enable earlier diagnosis, reducing disease severity at presentation and alleviating the financial burden on the public healthcare system.⁽¹³⁾

The study highlights critical disparities in prostate cancer management in Brazil, addressing a socially and medically important issue. One strength of the study was its robust analysis based on a large and diverse sample of 2,387 patients treated between 2017 and 2024. The inclusion of a public healthcare institution and a private institution ensured a balanced representation of healthcare services in Brazil, allowing for a more comprehensive understanding of disparities. The study also included the same percentage of patients older than 75 years in both groups, providing a consistent basis for evaluating clinical and geriatric decision-making, particularly as survival rates were shown to be worse among this age group. Our findings emphasize that Black (OR=2.27) and mixed-race (OR=1.89) patients are significantly more likely to present with metastatic disease compared to white patients, and those in the SUS are 2.5 times more likely to be diagnosed at advanced stages. This underscores the study's capacity to identify structural inequities, such as geographic barriers, with patients living over 10km from treatment centers being 95% less likely to access robotic surgery (OR=0.05). Furthermore, the study's use of well-defined statistical methods and clear significance thresholds (p<0.01) ensured its analytical rigor. The study's practical recommendations, like targeted screening programs and expanded access to advanced treatments, further highlight its strength in translating data into actionable solutions for policymakers and healthcare providers.

Despite these strengths, the study has several limitations. Only 58% of patients reported their race (1387 patients), with a low proportion of Black (7.35%) and mixed-race (13.84%) patients, limiting the generalizability of racial disparities and introducing a risk of confirmation bias. The analysis of geographic barriers is another area of weakness, as it lacks data on transportation infrastructure or patient-specific locations, which could provide greater context for these findings. A major limitation is that most Black patients were part of the SUS, making comparisons between groups less balanced and caution should be used when interpreting the analysis. The influence of race lost statistical significance in the multivariate model whereas the hospital variable remained significant, suggesting that the disparity is driven more by the healthcare system than by race. Additionally, public healthcare patients were three times more likely to be diagnosed with metastatic prostate cancer, which limited their access to surgery in general, not just robotic surgery. Although the hospitals had high patient volumes, the study's reliance on only two institutions restricts its representativeness across different regions of Brazil, particularly underserved areas. Another limitation was the fact that access to robotic surgery is significantly easier at private services, combined with the fact that most patients in the study were treated in the private system. The lack of robotic surgery for public health system patients and Black patients could be primarily due to the absence of technology at the public hospital, rather than a treatment choice made by healthcare providers. Finally, the lack of detailed socioeconomic data, such as patient income and education levels, limits the depth of the analysis and its ability to fully capture the socioeconomic drivers of the disparities observed.

The findings of this study reinforce the critical role of racial disparities in prostate cancer outcomes in Brazil. Black patients, particularly those treated in the public healthcare system, face significant barriers to early diagnosis and access to advanced treatments, leading to poor outcomes and high healthcare costs. Patients living more than 10 km away from treatment centers also encounter significant barriers to accessing robotic surgery, further amplifying these disparities. Older patients and those diagnosed with metastasis have lower chances of receiving advanced treatments and shorter survival, highlighting the need for targeted interventions for these vulnerable populations. In contrast, private institutions demonstrate better outcomes due to access to advanced technologies and early diagnoses. Public policies aimed at Afro-descendant patients and residents in more distant areas are required to reduce these disparities, improve survival rates, and enhance quality of life. Expanding early screening programs and increasing access to advanced treatments, such as robotic surgery, in public hospitals are essential strategies to mitigate these inequities.