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Desmond C, Kaul S, Fleishman A, Korets R, Chang P, Wagner A, Kim SP, Aghdam N, Olumi AF, Gershman B. The association of patient and disease characteristics with the overtreatment of low-risk prostate cancer from 2010 to 2016. Prostate Cancer Prostatic Dis 2024:10.1038/s41391-024-00822-2. [PMID: 38555410 DOI: 10.1038/s41391-024-00822-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 03/05/2024] [Accepted: 03/18/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Although active surveillance is the preferred management for low-risk prostate cancer (PCa), some men remain at risk of overtreatment with definitive local therapy. We hypothesized that baseline characteristics may be associated with overtreatment and represent a potential source of health disparities. We therefore examined the associations of patient and disease characteristics with the surgical overtreatment of low-risk PCa. METHODS We identified men aged 45-75 years with cT1 cN0 cM0 prostate adenocarcinoma with biopsy Gleason score 6 and PSA < 10 ng/ml from 2010-2016 in the National Cancer Database (NCDB) and who underwent radical prostatectomy (RP). We evaluated the associations of baseline characteristics with clinically insignificant PCa (iPCa) at RP (i.e., "overtreatment"), defined as organ-confined (i.e., pT2) Gleason 3 + 3 disease, using multivariable logistic regression. RESULTS We identified 36,088 men with low-risk PCa who underwent RP. The unadjusted rate of iPCa decreased during the study period, from 54.7% in 2010 to 40.0% in 2016. In multivariable analyses adjusting for baseline characteristics, older age (OR 0.98, 95% CI 0.97-0.98), later year of diagnosis (OR 0.62, 95% CI 0.57-0.67 for 2016 vs. 2010), Black race (OR 0.85, 95% CI 0.79-0.91), treatment at an academic/research program (OR 0.82, 95% CI 0.73-0.91), higher PSA (OR 0.91, 95% CI 0.90-0.92), and higher number of positive biopsy cores (OR 0.87, 95% CI 0.86-0.88) were independently associated with a lower risk of overtreatment (iPCa) at RP. Conversely, a greater number of biopsy cores sampled (OR 1.01, 95% CI 1.01-1.02) was independently associated with an increased risk of overtreatment (iPCa) at RP. CONCLUSIONS We observed an ~27% reduction in rates of overtreatment of men with low-risk PCa over the study period. Several patient, disease, and structural characteristics are associated with detection of iPCa at RP and can inform the management of men with low-risk PCa to reduce potential overtreatment.
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Affiliation(s)
| | - Sumedh Kaul
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Aaron Fleishman
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ruslan Korets
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Peter Chang
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Andrew Wagner
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Simon P Kim
- Division of Urology, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Nima Aghdam
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Aria F Olumi
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Boris Gershman
- Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Awasthi S, Mahal BA, Park JY, Creed JH, Williams VL, Elkenawi A, Meadows SO, Pow-Sang JM, Lu-Yao G, Kelly WK, Lang DLY, Zgibor J, Rebbeck TR, Yamoah K. Substantial Gleason reclassification in Black men with national comprehensive cancer network low-risk prostate cancer - A propensity score analysis. Prostate Cancer Prostatic Dis 2022; 25:547-552. [PMID: 35194179 PMCID: PMC9838824 DOI: 10.1038/s41391-022-00510-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/21/2022] [Accepted: 02/03/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND Emerging evidence suggests that a subset of Black men with National Comprehensive Cancer Network (NCCN) low-risk prostate cancer (PCa) may harbor high volume and genomically aggressive disease. However, limited, and ambiguous research exist to evaluate the risk of extreme Gleason reclassification in Black men with low-risk PCa. METHODS This retrospective cohort study included 45,674 low-risk PCa patients who underwent prostatectomy and were not on active surveillance, from National Cancer Database (NCDB). A propensity score matched-pair design was employed, and the final cohort was limited to 1:1 matched 12,340 patients. Gleason score reclassification was used as primary endpoint. As such, any migration to pathologic Gleason score ≥7(3 + 4) was identified as overall, whereas migration to ≥7(4 + 3) was defined as extreme reclassification. A conditional Poisson regression model was used to estimate the risk of reclassification. Whereas spline model was used to estimate the impact of increasing time to treatment as a non-linear function on Gleason reclassification between race group. RESULTS Upon matching there were no differences in the baseline characteristics between race groups. In a matched cohort, higher proportion of low-risk Black men (6.6%) reported extreme reclassification to pathologic Gleason score than White men (5.0%), p < 0.001. In a conditional Poisson regression model adjusted for time to treatment, the risk of overall (RR = 1.09, 95% CI, 1.05-1.13, p < 0.001) and extreme (RR = 1.30, 95% CI, 1.12-1.50, p = 0.004) reclassification was significantly higher in Black men as compared to their White counterpart. In spline model, the probability of Gleason reclassification in Black men was elevated with increasing time to treatment, especially after 180 days (53% vs. 43% between Black and White men). CONCLUSION Risk of Gleason score reclassification is disparately elevated in Black men with low-risk PCa. Furthermore, time to treatment can non-linearly impact Gleason reclassification in Black men.
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Affiliation(s)
- Shivanshu Awasthi
- Department of Cancer Epidemiology, H Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Brandon A. Mahal
- University of Miami Miller School of Medicine (MSOM)-Sylvester Comprehensive Cancer Center (SCCC), Miami, FL, USA
| | - Jong Y. Park
- Department of Cancer Epidemiology, H Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Jordan H. Creed
- Department of Health Informatics, H Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Vonetta L. Williams
- Collaborative Data Services Core, H Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Asmaa Elkenawi
- Department of Cancer Epidemiology, H Lee Moffitt Cancer Center, Tampa, FL, USA
| | | | - Julio M. Pow-Sang
- Department of Genitourinary Oncology, H Lee Moffitt Cancer Center, Tampa, FL, USA
| | - Grace Lu-Yao
- Thomas Jefferson University and Sidney Kimmel Cancer Center, Philadelphia, PA, USA
| | - Wm. Kevin Kelly
- Thomas Jefferson University and Sidney Kimmel Cancer Center, Philadelphia, PA, USA
| | | | - Janice Zgibor
- College of Public Health University of South Florida, Tampa, FL, USA
| | - Timothy R. Rebbeck
- Harvard T.H Chan School of Public Health and Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kosj Yamoah
- Department Cancer Epidemiology and Radiation Oncology, H Lee Moffitt Cancer Center, Tampa, FL, USA.,Correspondence and requests for materials should be addressed to Kosj Yamoah.
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Hoffman RM, Mott SL, McDowell BD, Anand ST, Nepple KG. Trends and practices for managing low-risk prostate cancer: a SEER-Medicare study. Prostate Cancer Prostatic Dis 2022; 25:100-108. [PMID: 34108645 PMCID: PMC8976291 DOI: 10.1038/s41391-021-00393-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/29/2021] [Accepted: 05/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Expectant management (EM) has been widely recommended for men with low-risk prostate cancers (PCa). We evaluated trends in EM and the sociodemographic and clinical factors associated with EM, initiating a National Comprehensive Cancer Network guideline-concordant active surveillance (AS) monitoring protocol, and switching from EM to active treatment (AT). METHODS We used the SEER-Medicare database to identify men ages 66+ diagnosed with a low-risk PCa (PSA < 10 ng/mL, Gleason ≤ 6, stage ≤ T2a) in 2010-2013 with ≥1 year of follow-up. We used claims data to capture (1) PCa treatments, including surgical procedures, radiotherapy, and hormone therapy, and (2) AS monitoring procedures, including PSA tests and prostate biopsy. We defined EM as receiving no AT within 1 year of diagnosis. We used multivariable regression techniques to identify factors associated with EM, initiating AS monitoring, and switching to AT. RESULTS During the study period, EM increased from 29.4% to 49.0%, p < 0.01. Age < 77, being married/partnered, non-Hispanic ethnicity, higher median ZIP code income, lower PSA levels, stage T1c, and more recent year of diagnosis were associated with EM. Nearly 39% of the EM cohort initiated AS monitoring; age <77, White race, being married/partnered, higher median ZIP code income, and lower PSA levels were associated with initiating AS. By three years after diagnosis, 21.3% of the EM cohort had switched to AT, usually after undergoing AS monitoring procedures. DISCUSSION We found increasing uptake of EM over time, though over 50% still received AT. About 60% of EM patients did not initiate AS monitoring, even among those with life expectancy >10 years, implying that a substantial proportion was being managed by watchful waiting. AS monitoring was associated with switching to AT, suggesting that treatment decisions likely were based on cancer progression.
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Affiliation(s)
- Richard M Hoffman
- Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA.
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA.
| | - Sarah L Mott
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Bradley D McDowell
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Sonia T Anand
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Kenneth G Nepple
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City, IA, USA
- Department of Urology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Vitzthum LK, Nalawade V, Riviere P, Sumner W, Nelson T, Mell LK, Furnish T, Rose B, Martínez ME, Murphy JD. Racial, Ethnic, and Socioeconomic Discrepancies in Opioid Prescriptions Among Older Patients With Cancer. JCO Oncol Pract 2021; 17:e703-e713. [PMID: 33534647 DOI: 10.1200/op.20.00773] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Minority race and lower socioeconomic status are associated with lower rates of opioid prescription and undertreatment of pain in multiple noncancer healthcare settings. It is not known whether these differences in opioid prescribing exist among patients undergoing cancer treatment. METHODS AND MATERIALS This observational cohort study involved 33,872 opioid-naive patients of age > 65 years undergoing definitive cancer treatment. We compared rates of new opioid prescriptions by race or ethnicity and socioeconomic status controlling for differences in baseline patient, cancer, and treatment factors. To evaluate downstream impacts of opioid prescribing and pain management, we also compared rates of persistent opioid use and pain-related emergency department (ED) visits. RESULTS Compared with non-Hispanic White patients, the covariate-adjusted odds of receiving an opioid prescription were 24.9% (95% CI, 16.0 to 33.9, P < .001) lower for non-Hispanic Blacks, 115.0% (84.7 to 150.3, P < .001) higher for Asian-Pacific Islanders, and not statistically different for Hispanics (-1.0 to 14.0, P = .06). There was no significant association between race or ethnicity and persistent opioid use or pain-related ED visits. Patients living in a high-poverty area had higher odds (53.9% [25.4 to 88.8, P < .001]) of developing persistent use and having a pain-related ED visit (39.4% [16.4 to 66.9, P < .001]). CONCLUSION For older patients with cancer, rates of opioid prescriptions and pain-related outcomes significantly differed by race and area-level poverty. Non-Hispanic Black patients were associated with a significantly decreased likelihood of receiving an opioid prescription. Patients from high-poverty areas were more likely to develop persistent opioid use and have a pain-related ED visit.
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Affiliation(s)
- Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University, Stanford, CA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Paul Riviere
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Whitney Sumner
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Tyler Nelson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Timothy Furnish
- Division of Pain Management, Department of Anesthesiology, University of California San Diego, La Jolla, CA
| | - Brent Rose
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - María Elena Martínez
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
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Etzioni R, Nyame YA. Prostate Cancer Screening Guidelines for Black Men: Spotlight on an Empty Stage. J Natl Cancer Inst 2020; 113:650-651. [PMID: 33146382 DOI: 10.1093/jnci/djaa172] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 01/24/2023] Open
Affiliation(s)
- Ruth Etzioni
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Yaw A Nyame
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Urology, University of Washington Medical Center, Seattle, WA, USA
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