Rates and predictors of colorectal cancer screening by race among motivated men participating in a Prostate Cancer Risk Assessment Program

BACKGROUND:

Screening by fecal occult blood test and lower endoscopy has lowered colorectal cancer (CRC) mortality, but compliance gaps persist. Of concern are possible disparities in uptake of CRC screening between white and African American men. The goal of this study was to assess for disparities in uptake of CRC screening among men participating in a high‐risk prostate cancer clinic. If present, such disparities could support hypotheses for further research examining racial differences in awareness and patient preferences in undergoing CRC screening.

METHODS:

Baseline data on a racially diverse cohort of men aged 50 to 69 years at increased risk of prostate cancer collected via the Prostate Cancer Risk Assessment Program at Fox Chase Cancer Center were analyzed. Predictors of uptake of CRC screening were assessed using multivariate logistic regression.

RESULTS:

Compared with whites, African American men had statistically significantly lower uptake of fecal occult blood testing (African American 49.0% vs white 60.7%, P = .035), lower endoscopy (African American 44.1% vs white 58.5%, P = .011), and any CRC screening (African American 66.2% vs white 76.3%, P = .053). Predictors of uptake of lower endoscopy among African American men included older age (odds ratio [OR], 3.61; 95% confidence interval [CI], 1.87‐6.97), family history of CRC (OR, 3.47; 95% CI, 1.30‐9.25), and insurance status (OR, 1.90; 95% CI, 1.04‐3.46).

CONCLUSIONS:

Despite awareness of cancer risk and motivation to seek prostate cancer screening through a specialized prostate cancer risk assessment program, evidence supporting compliance gaps with CRC screening among men was found. Tailored messages to younger African American men with and without a family history of CRC are needed. Cancer 2011;. © 2011 American Cancer Society.     

Impact of race on biochemical disease recurrence after prostate brachytherapy

BACKGROUND:

Understanding racial differences in disease presentation and response to therapy is necessary for the effective treatment and control of prostate cancer. In this study, the authors examined the influence of race on biochemical disease‐free survival (BDFS) among men who received prostate brachytherapy.

METHODS:

In total, 2301 men were identified who had a minimum follow‐up of 24 months and had received low‐dose‐rate brachytherapy for prostate cancer at the Mount Sinai Medical Center from June 1990 to October 2008. Patient factors, with specific emphasis on patient race, were analyzed with respect to freedom from biochemical failure (FFbF). Kaplan‐Meier analyses, life‐tables, and log‐rank tests were used to identify variables that were predictive of 10‐year FFbF.

RESULTS:

In this series, a total of 2268 patients included 81% Caucasians, 12% African Americans, 6% Hispanics, and 1% Asians. The 10‐year actuarial FFbF rate was 70% for AA men and 84% for all others (P = .002). Between Caucasian men and AA men, the 10‐year FFbF rate was 83% versus 70%, respectively (P = .001).There was no significant difference in 10‐year FFbF between Caucasian men and Hispanic men (83% vs 86%, respectively; P = .6). The 10‐year FFbF rate for Hispanic men and AA men was 86% versus 70%, respectively (P = .062). A greater percentage of AA men presented with higher prostate‐specific antigen levels (PSA) (>10 ng/mL; 44% vs 21%; P < .001) and, thus, with higher risk disease (24% vs 15%; P < .001) compared with Caucasian men. Among the men with low‐risk disease, the 10‐year FFbF rate was 90% for Caucasian men and 76% for AA men (P = .041). The 10‐year BDFS rate for patients who received brachytherapy alone was 86% for Caucasian men and 61% for AA men (P = .001); however, this difference was not observed when brachytherapy was combined with androgen‐deprivation therapy(ADT) with or without supplemental external‐beam radiotherapy (EBRT). Multivariate analysis revealed that PSA (P = .024), Gleason score (P < .001), the biologic effective dose (P < .001), EBRT (P = .002), ADT (P = .03), and AA race (P = .037) were significant predictors of 10‐year FFbF. No significant differences was observed in overall survival, cause‐specific survival, or distant metastasis‐free survival between racial groups.

CONCLUSIONS:

AA race appeared to be an independent negative predictor of BDFS after prostate brachytherapy, and this result may highlight the need for more aggressive therapy in this patient population. Cancer 2011;. © 2011 American Cancer Society.     

Treatment adherence and outcome in women with inflammatory breast cancer

BACKGROUND:

The authors compared treatment adherence rates and outcome in Caucasian and African American patients with inflammatory breast cancer (IBC).

METHODS:

The records of 55 (25 Caucasian and 30 African American) IBC patients treated with curative intent from 1995 to 2009 were reviewed. All patients received neoadjuvant doxorubicin (Adriamycin) and/or taxane‐based chemotherapy, and mastectomy with or without radiotherapy. The median follow‐up period for Caucasian and African American patients was similar (39.5 months and 36.1 months, respectively).

RESULTS:

There was no difference between races in median age, tumor size, grade, and receptor status at diagnosis. The number of patients who completed neoadjuvant chemotherapy, surgery, and radiotherapy did not differ by race (84% of Caucasians vs 86.7% of African Americans) nor did the median length of time to complete trimodality treatment (263 [range, 207‐422] days for Caucasians vs 262 [range, 165‐371] days for African Americans). There was a trend toward slightly higher pathological complete response rates in Caucasian than African American women (20% in Caucasians vs 6.7% in African Americans, P = .23). Despite slightly better response rates to neoadjuvant chemotherapy, Caucasian patients did not have higher 3‐year local control rates (70% in Caucasians vs 64% in African Americans, P = .73). However, there was a trend toward higher 3‐year overall survival in Caucasian versus African American patients (73% in Caucasians vs 55% in African Americans, P = .09) and higher distant metastasis‐free survival (60% in Caucasians vs 40% in African Americans, P = .19).

CONCLUSIONS:

This study is among the largest to examine patients with IBC by race. Being Caucasian or African American did not appear to impact treatment adherence. However, African American patients tended to have poorer response to standard treatment and worse outcome than Caucasian patients. Cancer 2011;. © 2011 American Cancer Society.     

Distress,anxiety, depression,and emotional well‐being in African‐American men with prostate cancer

Objective: African‐American men have an incidence rate of prostate cancer 60% higher than Caucasian men. Over one‐quarter of men with prostate cancer experience significant distress, yet psychosocial research has rarely focused on African‐American men. This study presents novel data on emotional well‐being, distress, anxiety, and depression in African‐American men with prostate cancer. Methods: This archival research combined two databases (N=385 and N=367) comprised of 55 African‐American men with prostate cancer. Quality of life was assessed with the Functional Assessment of Cancer Therapy, distress was measured with the Distress Thermometer, and anxiety and depression were measured with the Hospital Anxiety and Depression Scale. African‐American and Caucasian men were matched on age, education, and stage of disease, and compared on emotional well‐being, distress, anxiety, and depression. Results: The mean age of the 55 African‐American was 63 years old. In non‐matched comparison, African‐American men had elevated levels of distress, anxiety, and depression similar to Caucasian men. African‐American men reported high levels of clinically significant distress (>31%) and anxiety (>23%). However, after matching the African‐American and Caucasian men, African‐American men reported higher mean scores on emotional well‐being (p<0.05) and a lower percentage of African‐American men displayed clinically significant depressive symptoms (p<0.05) compared with Caucasian men. Conclusions: After matching the sample, African‐American men seem to display a sense of resilience, demonstrating greater emotional well‐being and a lower incidence of clinically significant depressive symptoms, compared with Caucasian men. This is consistent with cross‐cultural research outside of prostate cancer. Continued research is needed to further elucidate the concept of resiliency in African‐American men with prostate cancer. Copyright © 2010 John Wiley & Sons, Ltd.     

Racial differences in medical mistrust among men diagnosed with prostate cancer

BACKGROUND:

Mistrust of healthcare providers and systems is a significant barrier to quality healthcare. However, limited empirical data are available on perceptions of medical mistrust among individuals who are diagnosed with cancer. The objective of this study was to identify sociodemographic, clinical, and cultural determinants of mistrust among men diagnosed with prostate cancer.

METHODS:

The authors conducted an observational study among 196 African‐American men (n = 71) and white men (n = 125) who were newly diagnosed with prostate cancer during 2003 through 2007.

RESULTS:

Race, education, healthcare experiences, and cultural factors had significant effects on mistrust. African‐American men (P = .01) and men who had fewer years of formal education (P = .001) reported significantly greater levels of mistrust compared with white men and men who had more education. Mistrust also was greater among men who had been seeing their healthcare provider for a longer period (P = .01) and among men with lower perceptions of interdependence (P = .01).

CONCLUSIONS:

The current findings suggested that efforts to enhance trust among men who are diagnosed with prostate cancer should target African‐American men, men with fewer socioeconomic resources, and men with lower perceptions of interdependence. Reasons for deterioration in trust associated with greater experience with specialty providers should be explored along with the effects of interventions that are designed to address the concerns of individuals who have greater mistrust. Cancer 2009. © 2009 American Cancer Society.     

Racial disparities and socioeconomic status in men diagnosed with testicular germ cell tumors: a survival analysis

BACKGROUND:

Previous reports indicated that African‐American men with testicular germ cell tumors (TGCTs) have more aggressive tumor characteristics and less favorable outcomes than other men. The authors of this report evaluated the effects of race and socioeconomic status (SES) on stage distribution, overall mortality (OM), and cancer‐specific mortality (CSM) in men with TGCTs.

METHODS:

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify 22,553 men who were diagnosed with TGCTs between 1988 and 2006. Kaplan‐Meier and Cox regression analyses were generated to predict OM and CSM. Covariates of the analyses included race, SES, age, histologic subtype, disease stage, procedure type, SEER registry, and year of diagnosis. The interaction between race and SES also was examined.

RESULTS:

Overall, there were 516 African‐American men, 21,090 Caucasian men, and 947 men of other races. African‐Americans (14.9%) and individuals with low SES (10.7%) had a higher proportion of distant stage disease. CSM and OM rates were significantly higher for African‐American patients and for patients who resided in low SES counties. Multivariate analyses revealed that African‐American men and men with low SES were more likely to die of OM and CSM relative to Caucasian men (P < .001) and men with high SES (P < .001), respectively. The interaction between race and SES was not significant.

CONCLUSIONS:

African‐American race and low SES appeared to predispose men to more advanced disease stages and to higher OM and CSM rates. These observations may warrant race‐specific and/or SES‐specific adjustments in the treatment of TGCT. Cancer 2011;. © 2011 American Cancer Society.     

Disparities in medical care among commercially insured patients with newly diagnosed breast cancer

BACKGROUND:

African‐American women have increased breast cancer mortality compared with white women. Diagnostic and treatment gaps may contribute to this disparity.

METHODS:

In this retrospective, longitudinal cohort study, Southern US health plan claims data and linked medical charts were used to identify racial disparities in the diagnoses, treatment, and mortality of commercially insured women with newly diagnosed breast cancer. White women (n = 476) and African‐American women (n = 99) with newly diagnosed breast cancer were identified by breast cancer claims codes (International Classification of Diseases, Ninth Revision, Clinical Modification codes 174, 233.0, 238.3, and 239.3) between January 2000 and December 2004. Race, diagnoses (breast cancer stage, estrogen/progesterone receptor [ER/PR]‐positive status), treatment (breast‐conserving surgery, antiestrogen therapy, and chemotherapy interruption or reduction), and all‐cause mortality were assessed from medical charts. Multivariate regression analyses were adjusted for age, geography, and socioeconomic status to test the association of race with diagnoses/treatment.

RESULTS:

White women were older (P < .001) and had higher rates of diagnosis at stage 0/I (55.2% vs 38.4%; P < .05) than African‐American women. More white women had positive ER/PR status (75% vs 56% African‐American; P = .001) and received antiestrogen therapy if they were positive (37.2% vs 27.3% African‐American; P < .001). White women received slightly more breast‐conserving surgery and chemotherapy dose modification than African‐American women (P value nonsignificant). African‐American women had a higher mortality rate (8.1%) than white women (3.6%; P = .06). In adjusted analyses, African‐American women were diagnosed at later stages (odds ratio, 1.71; P = .02), and white women received more antiestrogen therapy (odds ratio, 2.1; P = .03).

CONCLUSIONS:

Disparities in medical care among patients with newly diagnosed breast cancer were evident between African‐American women and white women despite health plan insurance coverage. Interventions that address the gaps identified are needed. Cancer 2010. © 2010 American Cancer Society.     

Risk of dying from prostate cancer in men randomized to screening

BACKGROUND:

Although the true benefits and disadvantages of prostate cancer screening are still not known, the analysis of fatal cases is important for increasing knowledge of the effects of prostate cancer screening on mortality. Who dies from prostate cancer despite participation in a population‐based prostate‐specific antigen (PSA) screening program?

METHODS:

From the Goteborg branch of the European Randomized study of Screening for Prostate Cancer, 10,000 men randomly assigned to active PSA‐screening every second year formed the basis of the present study. Prostate cancer mortality was attributed to whether the men were attendees in the screening program (attending at least once) or nonattendees.

RESULTS:

Thirty‐nine men died from prostate cancer during the first 13 years. Both overall (34% vs 13 %; P < .0001) and cancer‐specific mortality (0.8% vs 0.3 %; P < .005) were found to be significantly higher among nonattendees compared with attendees. Furthermore, the majority of deaths (12 of 18) among screening attendees were in men diagnosed at first screening (prevalent cases). Only 6 deaths (including 3 interval cases) were noted among men complying with the biennial screening program.

CONCLUSIONS:

Nonattendees in prostate cancer screening constitute a high‐risk group for both death from prostate cancer and death from other causes comparable to that described in other cancer screening programs. Cancer 2009. © 2009 American Cancer Society.     

Prostate cancer treatment for economically disadvantaged men

BACKGROUND.

The authors compared the types of treatments prostate cancer patients received from county hospitals and private providers as part of a statewide public assistance program.

METHODS.

This was a cohort study of 559 men enrolled in a state‐funded program for low‐income patients known as Improving Access, Counseling, and Treatment for Californians With Prostate Cancer (IMPACT). Multinomial regression was used to compare types of treatments patients received from different providers.

RESULTS.

Between 2001 and 2006, 315 (56%) participants received treatment from county hospitals and 244 (44%) from private providers. There were no significant between‐group differences with respect to age (P = .22), enrollment year (P = .49), Charlson comorbidity index (P = .47), Gleason sum (P = .33), clinical T stage (P = .36), prostate‐specific antigen (P = .39), or D'Amico risk criteria (P = .45). Participants treated by private providers were more likely than those treated in county hospitals to be white (35% vs 10%, P < .01) and less likely to undergo surgery (29% vs 54%, P < .01). Multinomial regression analyses showed that participants treated by private providers were nearly 2½ times more likely than those treated by public providers to receive radiotherapy (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.37‐4.07) and >4½ times more likely to receive primary androgen deprivation (OR, 4.71; 95% CI, 2.15‐10.36) than surgery.

CONCLUSIONS.

In this economically disadvantaged cohort, prostate cancer treatments differed significantly between county hospitals and private providers. These data reveal substantial variations in treatment patterns between different types of healthcare institutions that—given the implications for health policy and quality of care—merit further scrutiny. Cancer 2010. © 2010 American Cancer Society.     

Improvement of racial disparities with respect to the utilization of minimally invasive radical prostatectomy in the United States

BACKGROUND:

Race represents an established barrier to health care access in the United States and elsewhere. We examined whether race affects the utilization rate of minimally invasive radical prostatectomy (MIRP) in a population‐based sample of individuals from the United States.

METHODS:

Within the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS), we focused on patients in whom MIRP and open radical prostatectomy (ORP) were performed between 2001 and 2007. We assessed the proportions and temporal trends in race distributions between MIRP and ORP. Multivariable logistic regression analyses further adjusted for age, year of surgery, baseline Charlson Comorbidity Index, annual hospital caseload tertiles, hospital region, insurance status, and median zip code income.

RESULTS:

Of 65,148 radical prostatectomies, 3581 (5.5%) were MIRPs. African Americans accounted for 11.4% of patients versus 78.8% for Caucasians versus 9.9% for others. Between 2001 and 2007, the annual proportions of Caucasian patients treated with MIRP were 2.2%, 0.9%, 2.6%, 7.2%, 4.7%, 9.3%, and 11.6%, respectively (chi‐square trend p<0.001). For the same years in African American patients, the proportions were 0.8, 0.3, 1.4, 4.4, 3.5, 9.0 and 8.4% (chi‐square trend P < .001). In multivariable analyses relative to Caucasian patients, African American patients were 14% less likely to undergo MIRP (P = .01). After period stratification between years 2001‐2005 versus 2006‐2007, African Americans were 22% less likely to undergo a MIRP in the early period (P = .007) versus 11% less likely to have a MIRP in the contemporary period (P = .1).

CONCLUSIONS:

The racial discrepancies in MIRP utilization rates are gradually improving. Cancer 2012;. © 2011 American Cancer Society.     

Disparities in survival among women with invasive cervical cancer

BACKGROUND:

In this study, the authors sought to understand the effects of patient race, ethnicity, and socioeconomic status (SES) on outcomes for cervical cancer.

METHOD:

The Florida Cancer Data System and the Agency for Health Care Administration data sets (1998‐2003) were merged and queried. Survival outcomes for patients with invasive cervical cancer were compared between different races, ethnicities, and community poverty levels.

RESULTS:

In total, 5367 patients with cervical cancers were identified. The overall median survival was 43 months. Significantly longer survival was observed for Caucasians (47.1 months vs 28.8 months for African Americans [AA]; P < .001), Hispanics (52.8 months vs 41.6 months for non‐Hispanics; P < .001), the insured (63 months vs 41.2 months for uninsured; P < .001), and patients from more affluent communities (53.3 months where <5% lived in poverty vs 36.9 months where >15% lived in poverty; P < .001). Surgery was associated with dramatically improved survival. AA women who were diagnosed with cervical cancer were significantly less likely to undergo surgical treatment with curative intent compared with Caucasian women (P < .001). However, on multivariate analysis, independent predictors of poorer outcomes were insurance status, tumor stage, tumor grade, and treatment. Neither race, nor ethnicity, nor SES was an independent predictor of poorer outcome.

CONCLUSIONS:

Race, ethnic, and SES disparities in cervical cancer survival were explained by late‐stage presentation and under‐treatment. Earlier diagnosis and greater access to surgery and other treatments would significantly improve the survival of women with cervical cancer. Cancer 2009. © 2008 American Cancer Society.     

Association between exercise and primary incidence of prostate cancer

BACKGROUND:

Exercise is a modifiable lifestyle risk factor associated with prostate cancer risk reduction. However, whether this association is different as a function of race is unclear. In the current study, the authors attempted to characterize the link between exercise and prostate cancer (CaP) in white and black American men.

METHODS:

Using a prospective design, 307 men (164 of whom were white and 143 of whom were black) who were undergoing prostate biopsy completed a self‐reported survey that assessed exercise behavior (metabolic equivalent [MET] hours per week). Crude and adjusted logistic regression analyses were used to estimate the risk of prostate cancer controlling for age, body mass index, digital rectal examination findings, previous biopsy, Charlson comorbidity score, and family history of CaP stratified by self‐reported race.

RESULTS:

There was no significant difference noted with regard to the amount of exercise between racial groups (P = .12). Higher amounts of MET hours per week were associated with a decreased risk of CaP for white men in both crude (P = .02) and adjusted (P = .04) regression models. Among whites, men who exercised ≥ 9 MET hours per week were less likely to have a positive biopsy result compared with men exercising < 9 MET hours per week (odds ratio, 0.47; 95% confidence interval, 0.22‐0.99 [P = .047]). There was no association noted between MET hours per week and risk of CaP among black men in both crude (P = .79) and adjusted (P = .76) regression models.

CONCLUSIONS:

In a prospective cohort of men undergoing biopsy, increased exercise, measured as MET hours per week, was found to be associated with CaP risk reduction among white but not black men. Investigating race‐specific mechanisms by which exercise modifies CaP risk and why these mechanisms disfavor black men in particular are warranted. Cancer 2013. © 2013 American Cancer Society.     

Survival disparities among African American women with invasive bladder cancer in Florida

BACKGROUND:

The authors sought to understand the effect of patient sex, race, and socioeconomic status (SES) on outcomes for bladder cancer.

METHOD:

The Florida Cancer Data System and the Agency for Health Care Administration data sets (1998‐2003) were merged and queried. Survival outcomes for patients with bladder cancer were compared between different races, ethnicities, and community poverty levels.

RESULTS:

A total of 31,100 people with bladder cancer were identified. Overall median survival time was 62.7 months. Statistically significantly longer survival times were observed in men (62.8 months vs 62.3 months for women), whites (63.0 months vs 39.6 months for African Americans [AAs], P < .001), non‐Hispanics (62.9 months vs 56.4 months for Hispanics, P < .001), and patients from more affluent communities (74.0 months where <5% live in poverty vs 53.0 months where >15% live in poverty, P < .001). Surgery was associated with dramatically improved survival. AA women diagnosed with bladder cancer were significantly less likely to have endoscopic surgical resection compared with white women (P < .001). On multivariate analysis, independent predictors of poorer outcomes were older age, AA race, female sex, degree of community poverty, histologic tumor grade, advanced tumor stage, and lack of surgical treatment.

CONCLUSIONS:

Racial and SES disparities in bladder cancer survival were not fully explained by late‐stage presentation and undertreatment. Although earlier diagnosis and greater access to surgery would likely yield some improvement in outcomes for AA women, more research is needed to understand the remaining survival gap for this population. Cancer 2009. © 2009 American Cancer Society.     

Impact of recent screening on predicting the outcome of prostate cancer biopsy in men with elevated prostate‐specific antigen

BACKGROUND:

Risk models to predict prostate cancer on biopsy, whether they include only prostate‐specific antigen (PSA) or other markers, are intended for use in all men of screening age. However, the association between PSA and cancer probably depends on a man's recent screening history.

METHODS:

The authors examined the effect of prior screening on the ability to predict the risk of prostate cancer by using a previously reported, 4‐kallikrein panel that included total PSA, free PSA, intact PSA, and human kallikrein‐related peptidase 2 (hK2). The study cohort comprised 1241 men in Gothenburg, Sweden who underwent biopsy for elevated PSA during their second or later visit for the European Randomized Study of Screening for Prostate Cancer. The predictive accuracy of the 4‐kallikrein panel was calculated.

RESULTS:

Total PSA was not predictive of prostate cancer. The previously published 4‐kallikrein model increased predictive accuracy compared with total PSA and age alone (area under the curve [AUC], 0.66 vs 0.51; P < .001) but was poorly calibrated and missed many cancers. A model that was developed with recently screened men provided important improvements in discrimination (AUC, 0.67 vs 0.56; P < .001). Using this model reduced the number of biopsies by 413 per 1000 men with elevated PSA, missed 60 of 216 low‐grade cancers (Gleason score ≤6), but missed only 1 of 43 high‐grade cancers.

CONCLUSIONS:

Previous participation in PSA screening dramatically changed the performance of statistical models that were designed to predict biopsy outcome. A 4‐kallikrein panel was able to predict prostate cancer in men who had a recent screening history and provided independent confirmation that multiple kallikrein forms contribute important diagnostic information for men with elevated PSA. Cancer 2010. © 2010 American Cancer Society.     

Inappropriate utilization of radiographic imaging in men with newly diagnosed prostate cancer in the United States

BACKGROUND:

The use of radiographic imaging (bone scan and computerized tomography) is only recommended for men diagnosed with high‐risk prostate cancer characteristics. The authors sought to characterize utilization patterns of imaging in men with newly diagnosed prostate cancer.

METHODS:

The authors performed a population‐based observational cohort study using the US Surveillance, Epidemiology, and End Results‐Medicare linked data to identify 30,183 men diagnosed with prostate cancer during 2004 to 2005.

RESULTS:

Thirty‐four percent of men with low‐risk and 48% with intermediate‐risk prostate cancer underwent imaging, whereas only 60% of men with high‐risk disease received imaging before treatment. Radiographic imaging utilization was greater for men who were older than 75 years (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.20‐1.37; P < .001), were black (OR, 1.11; 95% CI, 1.01‐1.21; P = .030), resided in wealthier areas (OR, 1.19; 95% CI, 1.08‐1.32 for median income >$60,000 vs <$35,000; P < .001), lived in rural regions (OR, 1.23; 95% CI, 1.12‐1.36; P < .001), or underwent standard radiation therapies (OR, 1.71; 95% CI, 1.60‐1.84; P < .001). Imaging utilization was less for men living in areas with greater high school education (OR, 0.83; 95% CI, 0.75‐0.91 between highest and lowest graduation rates; P < .001) or opting for active surveillance (OR, 0.17; 95% CI, 0.15‐0.19 vs radical prostatectomy; P < .001). The estimated cost of unnecessary imaging over this 2‐year period exceeded $3.6 million.

CONCLUSIONS:

In the United States, there is widespread overutilization of imaging for low‐risk and intermediate‐risk prostate cancer, whereas a worrisome number of men with high‐risk disease did not receive appropriate imaging studies to exclude metastases before therapy. Cancer 2012;. © 2011 American Cancer Society.     

Impact of race on survival in patients with clinically nonmetastatic prostate cancer who deferred primary treatment

BACKGROUND:

Prostate cancer (PCa) racial disparity studies typically focus on survival differences after curative treatment. The authors of this report hypothesized that comparing mortality rates between African American (AA) and Caucasian American (CA) patients who deferred primary treatment for clinically nonmetastatic PCa may provide a better assessment of the impact of race on the natural course of PCa.

METHODS:

The pathology database of the New York Veterans Administration Medical Center (VAMC), an equal access‐of‐care facility, was searched for patients with biopsy‐proven PCa. Inclusion criteria included 1) no evidence of metastatic disease or death within 3 years after diagnosis, 2) no primary treatment, and 3) a minimum of 5 years of follow‐up for survivors.

RESULTS:

In total, 518 patients met inclusion criteria between 1990 and 2005. AA patients were younger (P = .02) and had higher median prostate‐specific antigen (PSA) levels (P = .001) at the time of diagnosis compared with CA patients. In a multivariate model, higher Gleason score and PSA level were associated with increased mortality (P = .001 and P = .03, respectively), but race was not a predictor of death from PCa.

CONCLUSIONS:

The current data suggested that race did not have a major impact on survival in patients with PCa who deferred primary treatment for clinically nonmetastatic disease. Cancer 2012;118: 3145–52. © 2011 American Cancer Society.     

Predictors of clinical metastasis in prostate cancer patients receiving androgen deprivation therapy

BACKGROUND:

Virtually all patients with prostate cancer who receive androgen deprivation therapy (ADT) will ultimately develop evidence of resistance to treatment. The prognosis for patients who develop metastatic castrate‐resistant disease is reported to be poor, with overall survival historically estimated to be 24 to 36 months. The goal of the current study was to identify predictors of clinical disease progression in patients with prostate cancer who were receiving ADT.

METHODS:

Of the 13,740 men with biopsy–proven prostate cancer who were enrolled in the Cancer of the Prostate Strategic Urological Research Endeavor (CaPSURE) database from 1995 to 2007, 4003 men treated with ADT after diagnosis without evidence of metastases at treatment initiation were identified. The primary endpoint was the development of bone metastasis. Clinical and pathologic characteristics were compared between patients who developed metastasis and those who did not using chi‐square tests in a Cox proportional hazards regression model.

RESULTS:

The mean age of the men in the cohort was 70 years (range, 39‐94 years). One hundred ninety‐one men (4.8%) progressed to metastatic disease at a median of 18 months from the initiation of ADT (range, 1‐139 months). On multivariate analyses, risk category (hazards ratio [HR], 2.58; P < .0001), percent of biopsies positive >33% (HR, 3.36; P = .003), age ≤65 years at diagnosis (HR, 2.11; P = .001, and prostate–specific antigen velocity on ADT (HR, 1.04; P < .001) were found to be significantly associated with the development of metastatic disease after ADT.

CONCLUSIONS:

Younger men with high–risk disease appear to have worse prognosis than older men with similar disease. This, along with the other prognostic variables established in the current study, may help identify candidates for clinical trials evaluating secondary treatments for patients with castrate‐resistant disease. Cancer 2009. © 2009 American Cancer Society.     

Prostate cancer‐specific mortality and the extent of therapy in healthy elderly men with high‐risk prostate cancer

BACKGROUND:

The risk of prostate cancer‐specific mortality (PCSM) in healthy elderly men may depend on extent of treatment. The authors of this report compared the use of brachytherapy alone with combined brachytherapy, external‐beam radiation to the prostate and seminal vesicles, and androgen‐suppression therapy (CMT) in this population.

METHODS:

The study cohort comprised 764 men aged ≥65 years with high‐risk prostate cancer (T3 or T4N0M0, prostate‐specific antigen >20 ng/mL, and/or Gleason score 8‐10) who received either brachytherapy alone (n = 206) or CMT (n = 558) at the Chicago Prostate Cancer Center or at a 21st Century Oncology facility. Men either had no history of myocardial infarction (MI) or had a history of MI treated with a stent or surgical intervention. Fine and Gray regression analysis was used to identify the factors associated with PCSM.

RESULTS:

The median patient age was 73 years (interquartile range, 70‐77 years). After a median follow‐up of 4.9 years, 25 men died of prostate cancer. After adjusting for age and prostate cancer prognostic factors, the risk of PCSM was significantly less (adjusted hazard ratio, 0.29; 95% confidence interval, 0.12‐0.68; P = .004) for men who received CMT than for men who received brachytherapy alone. Other factors that were associated significantly with an increased risk of PCSM included a Gleason score of 8 to 10 (P = .017).

CONCLUSIONS:

Elderly men who had high‐risk prostate cancer without cardiovascular disease or with surgically corrected cardiovascular disease had a lower risk of PCSM when they received CMT than when they received brachytherapy alone. These results support aggressive locoregional treatment in healthy elderly men with high‐risk prostate cancer. Cancer 2010. © 2010 American Cancer Society.     

Statin medication use and the risk of biochemical recurrence after radical prostatectomy

BACKGROUND:

Although controversial, evidence suggests statins may reduce the risk of advanced prostate cancer (PC), and recently statin use was associated with prostate‐specific antigen (PSA) reductions among men without PC. The authors sought to examine the association between statin use and PSA recurrence after radical prostatectomy (RP).

METHODS:

The authors examined 1319 men treated with RP from the Shared Equal Access Regional Cancer Hospital (SEARCH) Database. Time to PSA recurrence was compared between users and nonusers of statin at surgery using Cox proportional hazards models adjusted for multiple clinical and pathological features.

RESULTS:

In total, 236 (18%) men were taking statins at RP. Median follow‐up was 24 months for statin users and 38 for nonusers. Statin users were older (P < .001) and underwent RP more recently (P < .001). Statin users were diagnosed at lower clinical stages (P = .009) and with lower PSA levels (P = .04). However, statin users tended to have higher biopsy Gleason scores (P = .002). After adjusting for multiple clinical and pathological factors, statin use was associated with a 30% lower risk of PSA recurrence (hazard ratio “HR”, 0.70; 95% confidence interval “CI”, 0.50‐0.97; P = .03), which was dose dependent (relative to no statin use; dose equivalent<simvastatin 20 mg: HR, 1.08; 95% CI, 0.66‐1.73; P = .78; dose equivalent = simvastatin 20 mg: HR, 0.57; 95% CI, 0.32‐1.00; P = .05; dose equivalent>simvastatin 20 mg: HR, 0.50; 95% CI, 0.27‐0.93; P = .03).

CONCLUSIONS:

In this cohort of men undergoing RP, statin use was associated with a dose‐dependent reduction in the risk of biochemical recurrence. If confirmed in other studies, these findings suggest statins may slow PC progression after RP. Cancer 2010. © 2010 American Cancer Society.     

Selective detection of histologically aggressive prostate cancer: an Early Detection Research Network Prediction model to reduce unnecessary prostate biopsies with validation in the Prostate Cancer Prevention Trial

BACKGROUND:

Limited survival benefit and excess treatment because of prostate‐specific antigen (PSA) screening in randomized trials suggests a need for more restricted selection of prostate biopsy candidates by discerning risk of histologically aggressive versus indolent cancer before biopsy.

METHODS:

Subjects undergoing first prostate biopsy enrolled in a multicenter, prospective cohort of the National Cancer Institute Early Detection Research Network (N = 635) were analyzed to develop a model for predicting histologically aggressive prostate cancers. The control arm of the Prostate Cancer Prevention Trial (N = 3833) was used to validate the generalization of the predictive model.

RESULTS:

The Early Detection Research Network cohort was comprised of men among whom 57% had no cancer, 14% had indolent cancer, and 29% had aggressive cancer. Age, body mass index, family history of prostate cancer, abnormal digital rectal examination (DRE), and PSA density (PSAD) were associated with aggressive cancer (all P < .001). The Early Detection Research Network model outperformed PSA alone in predicting aggressive cancer (area under the curve [AUC] = 0.81 vs 0.71, P < .01). Model validation in the Prostate Cancer Prevention Trial cohort accurately identified men at low (<10%) risk of aggressive cancer for whom biopsy could be averted (AUC = 0.78; 95% confidence interval, 0.75‐0.80). Under criteria from the Early Detection Research Network model, prostate biopsy can be restricted to men with PSAD >0.1 ng/mL/cc or abnormal DRE. When PSAD is <0.1 ng/mL/cc, family history or obesity can identify biopsy candidates.

CONCLUSIONS:

A predictive model incorporating age, family history, obesity, PSAD, and DRE elucidates criteria whereby ¼ of prostate biopsies can be averted while retaining high sensitivity in detecting aggressive prostate cancer. Cancer 2011. © 2011 American Cancer Society.