Socioeconomic Determinants of Prostate Cancer Outcomes: Challenging Racialized Narratives and Advancing Equitable Access in Ohio

Author: Anton Joao-Luz Allensworth, M.Ed.

Abstract

Prostate cancer mortality rates among African American men are frequently cited as evidence of racial predisposition. However, emerging research indicates that socioeconomic status (SES), access to care, and timing of diagnosis are more predictive of outcomes. This review critically examines the literature, including cohort studies of rural and Appalachian populations, and evaluates policy efforts such as Ohio House Bill 33. It concludes with recommendations for healthcare providers and policymakers to improve outreach and access for all men, regardless of race or income, with a focus on Ohio’s diverse communities.

Introduction

Prostate cancer is the second leading cause of cancer death among men in the United States. African American men are often reported to have the highest mortality rates, leading to widespread assumptions of biological susceptibility. However, this narrative lacks nuance and fails to account for the role of SES, healthcare access, and systemic barriers in shaping outcomes. In states like Ohio, where urban, rural, and Appalachian populations coexist, understanding these factors is critical to developing equitable public health strategies.

Racial Disparities in Context: The Role of SES

While African American men do experience higher mortality rates from prostate cancer, this disparity is largely attributable to late-stage diagnosis and limited access to care. When SES is controlled for, racial differences in outcomes diminish significantly. Men of all races with low income, limited insurance coverage, and poor access to healthcare facilities are less likely to receive timely screening and treatment.

A cohort study published in JAMA Network Open examined biochemical recurrence among 778 men with prostate cancer. Rural patients had a recurrence rate of 16.8%, compared to 8.5% among urban patients. Rural residence was independently associated with recurrence (HR, 1.74; 95% CI, 1.07–2.82), even after adjusting for treatment type, health status, and NCCN risk group. These findings underscore the impact of geographic and socioeconomic barriers on outcomes.

Appalachian Kentucky: A Mirror of Disparity

A population-based study from the University of Kentucky analyzed prostate cancer outcomes among men in Appalachian Kentucky. Compared to non-Appalachian counterparts, these men had higher Gleason scores, more distant disease at diagnosis, and lower rates of private insurance. Despite being predominantly white, Appalachian men exhibited survival outcomes similar to those often attributed to African American men, reinforcing the argument that SES—not race—is the primary determinant of prognosis.

These findings are particularly relevant to Ohio, which includes 32 counties designated as part of Appalachia. Many of these counties face similar challenges: high poverty rates, limited healthcare infrastructure, and low educational attainment. The parallels between Appalachian Kentucky and southeastern Ohio suggest that prostate cancer disparities in Ohio are not confined to racial lines but are deeply rooted in socioeconomic and geographic inequities.

Misinformation and Its Consequences

The narrative of racial predisposition can lead non-Black men to underestimate their risk, particularly those from underserved communities. This misperception reduces screening uptake and delays diagnosis. Additionally, attributing African American men's hesitancy to historical mistrust, such as the Tuskegee Syphilis Study oversimplifies the issue. Data indicate that lack of health education, insurance, and effective outreach are more significant barriers to screening.

Healthcare systems often fail to engage at-risk populations outside of African American communities, leaving rural white, Latino, and lower income non-Black populations to be underserved to not served. Outreach efforts must be inclusive and culturally competent to address these gaps. In Ohio, where urban centers like Cleveland and Columbus coexist with rural and Appalachian regions, a one-size-fits-all approach to prostate cancer education and screening is insufficient.

Policy Landscape: Uneven Access to Care in Ohio

Ohio House Bill 33 (HB 33) mandates insurance coverage for preventive prostate cancer screenings for men aged ≥40 years who are considered high-risk, including those with a family history or African American ancestry. While this is a positive step, the qualifying criteria may inadvertently reinforce racialized narratives and exclude other vulnerable populations, such as low-income rural men who share similar risk profiles.

In contrast, Ohio House Bill 371 (HB 371) provides universal access to breast cancer screening for all women, regardless of age or risk factors. This bill removes barriers and ensures equitable access to care. The disparity between HB 33 and HB 371 highlights a gender-based inequity in cancer prevention policy.

Section 1557 of the Affordable Care Act prohibits discrimination based on sex in federally funded health programs. However, in practice, ACA provisions have disproportionately benefited women. Preventive services such as mammograms and contraception are mandated, while equivalent coverage for prostate cancer screening remains inconsistent. This gap leaves many men—especially those without employer-sponsored insurance—without access to potentially life-saving preventive care.

Recommendations for Healthcare Providers and Policymakers

To address these disparities, the following actions are recommended:

1. Policy Reform – Expand HB 33 to include all men aged ≥40 years, regardless of race or family history. Align prostate cancer screening mandates with those for breast cancer to ensure gender equity.

2. Healthcare Provider Engagement – Implement routine risk assessments for all male patients, especially those from underserved communities. Provide culturally competent education about prostate cancer risk and screening options.

3. Outreach and Access – Deploy mobile testing units in rural and low-income urban areas, including Appalachian counties. Partner with community organizations to raise awareness and facilitate screening.

4. Public Awareness Campaigns – Challenge misinformation about racial predisposition. Promote inclusive messaging that emphasizes SES and access as key risk factors.

5. Community Engagement – Ensure that outreach efforts are visible and accessible. None of these initiatives will succeed if the populations they target are unaware of them.

Conclusion

Efforts to reduce prostate cancer disparities must move beyond race-based assumptions and address the structural determinants of health. Outreach initiatives, policy reforms, and provider education are essential—but they are ineffective if the intended populations remain unaware of them. The Crowns Project, through its initiatives, is committed to ensuring that all men have access to testing and treatment. By promoting equity in cancer care and engaging Ohio’s diverse communities, we can improve outcomes for all men, regardless of race, income, or geography.