Authors: Krishna S, Fan Y, Jarosek S, Adejoro O, Chamie K, Konety B
Title: Racial disparities in active surveillance for prostate cancer.
Journal: J Urol :-
Date: 2016 Sep 02
Abstract: INTRODUCTION AND OBJECTIVES: Active surveillance (AS) protocols track low-risk prostate cancer (PCa) progression over time. But given the lack of uniform criteria in managing low-risk PCa, men who qualify for AS might undergo less intensive surveillance and thus experience poorer outcomes. In our study, we examined racial disparities in the frequency and intensity of AS between African Americans (AAs) and Caucasian Americans (CAs). METHODS: Using the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset, we identified 13,374 men with low-risk PCa (defined by the D'Amico criteria) who were diagnosed from 2004-2009 and then followed through 2011. We found that 2,916 men did not undergo any treatment (radiation, hormonal therapy, or surgery) within 1 year after diagnosis. Men were deemed to be on AS if they underwent at least 1 of the following 3 surveillance strategies within 2 years after diagnosis: ≥1 prostate biopsy; ≥4 prostate-specific antigen (PSA) tests; and/or ≥4 visits to the doctor with PCa listed as the diagnosis. To compare the frequency of AS between the 2 groups (AAs vs. CAs), we used the chi-square test. To estimate the odds ratio (OR) of AS, we used multivariable logistic regression, after adjusting for possible confounders such as year of diagnosis, age at diagnosis, socioeconomic status, and Charlson score. RESULTS: Of the 2,916 untreated men, 1,141 (39%) of them-963 (37%) of the CAs vs. 178 (58%) of the AAs (P < 0.0001)-did not undergo any of the 3 surveillance strategies but instead, essentially, underwent watchful waiting (WW). CAs (vs. AAs) were more likely to be on AS, with 1,646 (63.1%) vs. 129 (42.0%) opting for 1 surveillance strategy (P<0.0001); 783 (30.0%) vs. 50 (16.3%) opting for any 2 strategies (P<0.0001); and 193 (7.4%) vs. 11 (3.6%) going through all 3 (P=0.01). In multivariable analysis, AAs had significantly lower odds of undergoing AS than did CAs (OR, 0.52; 95% confidence interval [CI], 0.40 to 0.67). Men with more comorbidities (Charlson score ≥1) had significantly higher odds of undergoing AS than WW (OR, 1.7; 95% CI, 1.46 to 2.12). CONCLUSIONS: In men untreated for low-risk PCa, CAs underwent AS more frequently than did AAs, who often defaulted to de facto WW after an initial period of AS. This discrepancy raises questions about the factors favoring WW over AS. Moreover, given the lack of consensus regarding the most efficient AS strategy, we anticipate that racial disparities in the use of AS will persist, especially in AAs.
Last Updated: 02 Mar 2015