Association of African American Race and Outcomes in Low-Risk Prostate Cancer With Active Surveillance | Health Disparities | JN Learning | AMA Ed Hub [Skip to Content]
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Health Disparities

Association Between African American Race and Clinical Outcomes in Men Treated for Low-Risk Prostate Cancer With Active Surveillance

Educational Objective
To learn whether active surveillance may be a safe option for African American men with low-risk prostate cancer.
1 Credit CME
JAMA
November 3, 2020
Original Investigation
Rishi Deka, PhD1,2;
P. Travis Courtney, MAS1,2;
J. Kellogg Parsons, MD, MHS1,3;
Tyler J. Nelson, BS1,2;
Vinit Nalawade, MS1,2;
Elaine Luterstein, BS1,2;
Daniel R. Cherry, MAS1,2;
Daniel R. Simpson, MD1,2;
Arno J. Mundt, MD2;
James D. Murphy, MD, MPH1,2;
Anthony V. D’Amico, MD, PhD4,5,6;
Christopher J. Kane, MD3;
Maria Elena Martinez, PhD7;
Brent S. Rose, MD1,2,3
Author Affiliations
  • 1VHA San Diego Health Care System, La Jolla, California
  • 2Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla
  • 3Department of Urology, University of California San Diego School of Medicine, La Jolla
  • 4Department of Radiation Oncology, Harvard Medical School, Cambridge, Massachusetts
  • 5Dana-Farber Cancer Institute, Harvard Medical School, Cambridge, Massachusetts
  • 6Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 7Department of Family Medicine and Public Health, University of California San Diego School of Medicine, La Jolla
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Key Points

Question  Is active surveillance a safe and effective option for African American men with low-risk prostate cancer?

Findings  In this retrospective cohort study that included 8726 men with low-risk prostate cancer followed up for a median of 7.6 years, African American men, compared with non-Hispanic White men, had a statistically significant increased 10-year cumulative incidence of disease progression (59.9% vs 48.3%) and definitive treatment (54.8% vs 41.4%), but not metastasis (1.5% vs 1.4%) or prostate cancer–specific mortality (1.1% vs 1.0%).

Meaning  Among African American men with low-risk prostate cancer, active surveillance was associated with increased risk of disease progression and definitive treatment compared with non-Hispanic White men, but not increased mortality; however, longer-term follow-up is needed to better understand mortality risk.

Abstract

Importance  There is concern that African American men with low-risk prostate cancer may harbor more aggressive disease than non-Hispanic White men. Therefore, it is unclear whether active surveillance is a safe option for African American men.

Objective  To compare clinical outcomes of African American and non-Hispanic White men with low-risk prostate cancer managed with active surveillance.

Design, Setting, and Participants  Retrospective cohort study in the US Veterans Health Administration Health Care System of African American and non-Hispanic White men diagnosed with low-risk prostate cancer between January 1, 2001, and December 31, 2015, and managed with active surveillance. The date of final follow-up was March 31, 2020.

Exposures  Active surveillance was defined as no definitive treatment within the first year of diagnosis and at least 1 additional surveillance biopsy.

Main Outcomes and Measures  Progression to at least intermediate-risk, definitive treatment, metastasis, prostate cancer–specific mortality, and all-cause mortality.

Results  The cohort included 8726 men, including 2280 African American men (26.1%) (median age, 63.2 years) and 6446 non-Hispanic White men (73.9%) (median age, 65.5 years), and the median follow-up was 7.6 years (interquartile range, 5.7-9.9; range, 0.2-19.2). Among African American men and non-Hispanic White men, respectively, the 10-year cumulative incidence of disease progression was 59.9% vs 48.3% (difference, 11.6% [95% CI, 9.2% to 13.9%); P < .001); of receipt of definitive treatment, 54.8% vs 41.4% (difference, 13.4% [95% CI, 11.0% to 15.7%]; P < .001); of metastasis, 1.5% vs 1.4% (difference, 0.1% [95% CI, –0.4% to 0.6%]; P = .49); of prostate cancer–specific mortality, 1.1% vs 1.0% (difference, 0.1% [95% CI, –0.4% to 0.6%]; P = .82); and of all-cause mortality, 22.4% vs 23.5% (difference, 1.1% [95% CI, –0.9% to 3.1%]; P = 0.09).

Conclusions and Relevance  In this retrospective cohort study of men with low-risk prostate cancer followed up for a median of 7.6 years, African American men, compared with non-Hispanic White men, had a statistically significant increased 10-year cumulative incidence of disease progression and definitive treatment, but not metastasis or prostate cancer–specific mortality. Longer-term follow-up is needed to better assess the mortality risk.

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Health Disparities Oncology Prostate Cancer Urology Urologic Cancer
Article Information

Corresponding Author: Brent S. Rose, MD, UC San Diego Health, Moores Cancer Center, 3855 Health Sciences Dr, La Jolla, CA 92093 (bsrose@ucsd.edu).

Accepted for Publication: August 27, 2020.

Author Contributions: Drs Deka and Rose had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Deka, Mundt, Murphy, Rose.

Acquisition, analysis, or interpretation of data: Deka, Courtney, Parsons, Nelson, Nalawade, Luterstein, Cherry, Simpson, Murphy, D’Amico, Kane, Martinez, Rose.

Drafting of the manuscript: Deka, Parsons, Cherry, Simpson, Rose.

Critical revision of the manuscript for important intellectual content: Deka, Courtney, Parsons, Nelson, Nalawade, Luterstein, Simpson, Mundt, Murphy, D’Amico, Kane, Martinez, Rose.

Statistical analysis: Deka, Courtney, Nalawade, Murphy, Rose.

Obtained funding: Rose.

Administrative, technical, or material support: Deka, Nelson, Cherry, Mundt, Murphy, D'Amico, Rose.

Supervision: Deka, Simpson, Kane, Rose.

Conflict of Interest Disclosures: Dr Courtney reported receiving grants from the National Institutes of Health (NIH). Dr Parsons reported receiving personal fees from Insightec and Endocare outside the submitted work. Dr Murphy reported receiving personal fees from Boston Consulting Group outside the submitted work. Dr Kane reported owning stock in Stratify Genomics, which is a company with a prostate cancer screening product. Dr Rose reported receiving grants from the Department of Defense. No other disclosures were reported.

Funding/Support: This study was supported by Department of Defense grant W81XWH-17-PCRP-PRA (Drs Deka and Rose) and NIH grant TL1-TR001443 (Messrs Courtney and Cherry). Drs Martinez and Rose received funding from NIH grant U54CA132379 and U54CA132384.

Role of the Funder/Sponsor: The funder/sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Sundi  D , Ross  AE , Humphreys  EB ,  et al.  African American men with very low-risk prostate cancer exhibit adverse oncologic outcomes after radical prostatectomy.   J Clin Oncol. 2013;31(24):2991-2997. PubMedGoogle ScholarCrossref
2.
Mahal  BA , Alshalalfa  M , Spratt  DE , Davicioni  E , Zhao  SG , Feng  FY ,  et al.  Prostate cancer genomic-risk differences between African American and White men across Gleason Scores.   Eur Urol. 2019;75(6):1038-1040. PubMedGoogle ScholarCrossref
3.
Mahal  BA , Berman  RA , Taplin  ME , Huang  FW .  Prostate cancer-specific mortality across Gleason scores in black vs nonblack men.   JAMA. 2018;320(23):2479-2481. PubMedGoogle ScholarCrossref
4.
Mahal  BA , Butler  S , Franco  I ,  et al.  Use of active surveillance or watchful waiting for low-risk prostate cancer and management trends across risk groups in the United States, 2010-2015.   JAMA. 2019;321(7):704-706. PubMedGoogle ScholarCrossref
5.
Odom  BD , Mir  MC , Hughes  S ,  et al.  Active surveillance for low-risk prostate cancer in African American men.   Urology. 2014;83(2):364-368. PubMedGoogle ScholarCrossref
6.
Iremashvili  V , Soloway  MS , Rosenberg  DL , Manoharan  M .  Clinical and demographic characteristics associated with prostate cancer progression in patients on active surveillance.   J Urol. 2012;187(5):1594-1599. PubMedGoogle ScholarCrossref
7.
Abern  MR , Bassett  MR , Tsivian  M ,  et al.  Race is associated with discontinuation of active surveillance of low-risk prostate cancer.   Prostate Cancer Prostatic Dis. 2013;16(1):85-90. PubMedGoogle ScholarCrossref
8.
Sundi  D , Faisal  FA , Trock  BJ ,  et al.  Reclassification rates are higher among African American men than Caucasians on active surveillance.   Urology. 2015;85(1):155-160. PubMedGoogle ScholarCrossref
9.
Davis  JW , Ward  JF  III , Pettaway  CA ,  et al.  Disease reclassification risk with stringent criteria and frequent monitoring in men with favourable-risk prostate cancer undergoing active surveillance.   BJU Int. 2016;118(1):68-76. PubMedGoogle ScholarCrossref
10.
National Comprehensive Cancer Network. Clinical practice guidelines in oncology. Accessed January 7, 2020. https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf
11.
Department of Veterans Affairs. About VHA. Accessed January 7, 2020. https://www.va.gov/health/aboutvha.asp
12.
Charlson  M , Szatrowski  TP , Peterson  J , Gold  J .  Validation of a combined comorbidity index.   J Clin Epidemiol. 1994;47(11):1245-1251. PubMedGoogle ScholarCrossref
13.
Coogan  PF , Castro-Webb  N , Yu  J , O’Connor  GT , Palmer  JR , Rosenberg  L .  Neighborhood and individual socioeconomic status and asthma incidence in African American women.   Ethn Dis. 2016;26(1):113-122. PubMedGoogle ScholarCrossref
14.
National Comprehensive Cancer Network. NCCN guidelines for patients: prostate cancer. Accessed January 10, 2020. https://www.nccn.org/patients/guidelines/prostate/files/assets/common/downloads/files/prostate.pdf
15.
Carter  HB , Kettermann  A , Warlick  C ,  et al.  Expectant management of prostate cancer with curative intent.   J Urol. 2007;178(6):2359-2364. PubMedGoogle ScholarCrossref
16.
Tosoian  JJ , Trock  BJ , Landis  P ,  et al.  Active surveillance program for prostate cancer.   J Clin Oncol. 2011;29(16):2185-2190. PubMedGoogle ScholarCrossref
17.
Klotz  L , Zhang  L , Lam  A , Nam  R , Mamedov  A , Loblaw  A .  Clinical results of long-term follow-up of a large, active surveillance cohort with localized prostate cancer.   J Clin Oncol. 2010;28(1):126-131. PubMedGoogle ScholarCrossref
18.
van As  NJ , Norman  AR , Thomas  K ,  et al.  Predicting the probability of deferred radical treatment for localised prostate cancer managed by active surveillance.   Eur Urol. 2008;54(6):1297-1305. PubMedGoogle ScholarCrossref
19.
Berglund  RK , Masterson  TA , Vora  KC , Eggener  SE , Eastham  JA , Guillonneau  BD .  Pathological upgrading and up staging with immediate repeat biopsy in patients eligible for active surveillance.   J Urol. 2008;180(5):1964-1967. PubMedGoogle ScholarCrossref
20.
Soloway  MS , Soloway  CT , Williams  S , Ayyathurai  R , Kava  B , Manoharan  M .  Active surveillance: a reasonable management alternative for patients with prostate cancer: the Miami experience.   BJU Int. 2008;101(2):165-169.PubMedGoogle Scholar
21.
Soloway  MS , Soloway  CT , Eldefrawy  A , Acosta  K , Kava  B , Manoharan  M .  Careful selection and close monitoring of low-risk prostate cancer patients on active surveillance minimizes the need for treatment.   Eur Urol. 2010;58(6):831-835. PubMedGoogle ScholarCrossref
22.
McClelland  S  III , Mitin  T .  The danger of applying the ProtecT Trial to minority populations.   JAMA Oncol. 2018;4(3):291. PubMedGoogle ScholarCrossref
23.
Dess  RT , Hartman  HE , Mahal  BA ,  et al.  Association of black race with prostate cancer-specific and other-cause mortality.   JAMA Oncol. 2019;5(7):975-983. PubMedGoogle ScholarCrossref
24.
DeSantis  CE , Siegel  RL , Sauer  AG ,  et al.  Cancer statistics for African Americans, 2016.   CA Cancer J Clin. 2016;66(4):290-308. PubMedGoogle ScholarCrossref
25.
Steele  CB , Li  J , Huang  B , Weir  HK .  Prostate cancer survival in the United States by race and stage (2001-2009).   Cancer. 2017;123(suppl 24):5160-5177. PubMedGoogle ScholarCrossref
26.
Noone  AM , Howlader  N , Krapcho  M ,  et al. SEER Cancer Statistics Review (CSR) 1975-2015. Accessed January 15, 2020. https://seer.cancer.gov/archive/csr/1975_2015/
27.
Katz  JE , Chinea  FM , Patel  VN ,  et al.  Disparities in Hispanic/Latino and non-Hispanic Black men with low-risk prostate cancer and eligible for active surveillance.   Prostate Cancer Prostatic Dis. 2018;21(4):533-538. PubMedGoogle ScholarCrossref
28.
Maurice  MJ , Sundi  D , Schaeffer  EM , Abouassaly  R .  Risk of pathological upgrading and up staging among men with low risk prostate cancer varies by race.   J Urol. 2017;197(3, pt 1):627-631. PubMedGoogle ScholarCrossref
29.
Gökce  MI , Sundi  D , Schaeffer  E , Pettaway  C .  Is active surveillance a suitable option for African American men with prostate cancer? a systemic literature review.   Prostate Cancer Prostatic Dis. 2017;20(2):127-136. PubMedGoogle ScholarCrossref
30.
Butler  S , Muralidhar  V , Chavez  J ,  et al.  Active surveillance for low-risk prostate cancer in Black patients.   N Engl J Med. 2019;380(21):2070-2072. PubMedGoogle ScholarCrossref
31.
Riviere  P , Luterstein  E , Kumar  A ,  et al.  Racial equity among African American and non-Hispanic White men diagnosed with prostate cancer in the Veterans Affairs Healthcare System.   Int J Radiat Oncol Biol Phys. 2019;105(1):E305. Google Scholar
32.
Tosoian  JJ , Mamawala  M , Epstein  JI ,  et al.  Intermediate and longer-term outcomes from a prospective active-surveillance program for favorable-risk prostate cancer.   J Clin Oncol. 2015;33(30):3379-3385. PubMedGoogle ScholarCrossref
33.
Klotz  L , Vesprini  D , Sethukavalan  P ,  et al.  Long-term follow-up of a large active surveillance cohort of patients with prostate cancer.   J Clin Oncol. 2015;33(3):272-277. PubMedGoogle ScholarCrossref
34.
Hamdy  FC , Donovan  JL , Lane  JA ,  et al; ProtecT Study Group.  10-Year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer.   N Engl J Med. 2016;375(15):1415-1424. PubMedGoogle ScholarCrossref
35.
Moghanaki  D , Howard  LE , De Hoedt  A ,  et al.  Validity of the National Death Index to ascertain the date and cause of death in men having undergone prostatectomy for prostate cancer.   Prostate Cancer Prostatic Dis. 2019;22(4):633-635. PubMedGoogle ScholarCrossref
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