Socioeconomic and Health Pathways Linking Race/Ethnicity to Prostate Cancer Severity: A Structural Equation Modeling Analysis

Objectives Prostate cancer screening guidelines emphasize shared decision-making, yet these decisions are shaped by structural contexts. While racial and ethnic disparities in outcomes are well-documented, the socioeconomic and pre-diagnostic health pathways driving these differences in later life remain unclear. This study utilized structural equation modeling (SEM) to evaluate whether socioeconomic status (SES) and pre-diagnostic health profiles mediate the relationship between race/ethnicity and clinical severity at prostate cancer diagnosis. Methods We analyzed 5,438 men aged 55 to 74 years diagnosed with prostate cancer in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. Parallel mediation SEM with weighted least squares estimation examined two pathways linking race/ethnicity to latent clinical severity (prostate-specific antigen (PSA), Gleason score, and stage): SES pathway and a pre-diagnostic health profile pathway (PSA screening history, comorbidity, and family history). Results The baseline latent severity model demonstrated acceptable fit (CFI = 0.872, TLI = 0.872, RMSEA = 0.034, SRMR = 0.027). Neither SES nor the measured pre-diagnostic health profile meaningfully mediated racial/ethnic differences in clinical severity. Compared with White men, total effects on latent clinical severity were significant only for AsAm men (0.465, 95% CI: 0.256 to 0.642). Predicted latent severity was highest among Asian men (1.659), followed by Black (1.155) and Hispanic (1.076). Conclusions These findings suggest that unmeasured mechanisms remain poorly understood in explaining racial and ethnic disparities in prostate cancer severity. Future studies incorporating richer social determinants measures and greater inclusion of underrepresented racial and ethnic groups may clarify pathways underlying these disparities.