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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
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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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.

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