Pathological outcome and biochemical recurrence-free survival after radical prostatectomy in African-American, Afro-Caribbean (Jamaican) and Caucasian-American men: an international comparison

The association of patient and disease characteristics with the overtreatment of low-risk prostate cancer from 2010 to 2016

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.

Evaluation of Survival Outcomes Among Black and White Patients with Metastatic Castration-resistant Prostate Cancer: A Systematic Review and Meta-analysis

Context

Data on racial disparities among patients with metastatic castration-resistant prostate cancer (mCRPC) are limited and there is no uniform conclusion on differences by race in this setting.

Objective

To provide the latest evidence on racial disparities in survival outcomes between Black and White patients receiving systemic therapies for mCRPC.

Evidence acquisition

Our study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We systematically searched the PubMed, Web of Science, and Cochrane Library databases up to September 2023 to identify potentially relevant studies. Overall survival (OS) and progression-free survival (PFS) were the outcomes of interest. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were evaluated.

Evidence synthesis

Nine studies involving 9462 patients with mCRPC (2058 Black and 7404 White men) met the eligibility criteria and were included. Pooled estimates demonstrated significantly better OS for Black than for White men (HR 0.75, 95% CI 0.70-0.80; p < 0.0001). The results were similar in a subgroup of men receiving androgen receptor-targeted therapies (HR 0.72, 95% CI 0.66-0.78; p < 0.0001) and a subgroup of men receiving other treatments (HR 0.79, 95% CI 0.71-0.88; p < 0.0001). Likewise, significantly favorable PFS was observed for Black men receiving ARTs in comparison to their White counterparts (HR 0.84, 95% CI 0.71-0.99; p = 0.0373).

Conclusions

Overall, our meta-analysis of survival outcomes for men with mCRPC stratified by race revealed a significant survival benefit for Black men in comparison to their White counterparts, regardless of systemic therapeutic agent.

Patient summary

Both biological and nonbiological factors could account for racial differences in the efficacy of systemic treatments for metastatic prostate cancer that is resistant to hormone therapy. Our review provides the latest reliable evidence showing better survival outcomes for Black than for White men. The results will be helpful in further understanding the molecular mechanisms that might explain racial differences in this disease stage and in planning treatment.

Trends in prostate cancer incidence among Black men in the Caribbean and the United States

BACKGROUND

Prostate cancer incidence is highest for Black men of the African diaspora in the United States and Caribbean. Recent changes in recommendations for prostate cancer screening have been shown to decrease overall prostate cancer incidence and increase the likelihood of late stage disease. However, it is unclear how trends in prostate cancer characteristics among high risk Black men differ by geographic region during the changes in screening recommendations.

METHODS

In this study, we used population-based prostate cancer registry data to describe age-adjusted prostate cancer incidence trends from 2008 to 2015 among Black men from six geographic regions. We obtained data on incident Black prostate cancer patients from six cancer registries (in the United States: Florida, Alabama, Pennsylvania, and New York; and in the Caribbean: Guadeloupe and Martinique). After age standardization, we used descriptive analyses to compare the demographics and tumor characteristics by cancer registry site. The Joinpoint regression program was used to compare the trends in incidence by site.

RESULTS

A total of 59,246 men were analyzed. We found the highest incidence rates (per 100,000) for prostate cancer in the Caribbean countries (181.99 in Martinique and 176.62 in Guadeloupe) and New York state (178.74). Incidence trends decreased significantly over time at all sites except Martinique, which also showed significantly increasing rates of late stage (III/IV) and Gleason score 7+ tumors.

CONCLUSIONS

We observed significant differences in prostate cancer incidence trends among Black men after major changes prostate screening recommendations. Future studies will examine the factors that differentially influence prostate cancer trends among the African diaspora.

Expression of Endogenous Retroviral RNA in Prostate Tumors has Prognostic Value and Shows Differences among Americans of African Versus European/Middle Eastern Ancestry

Simple Summary

Endogenous retroviruses (ERVs) are viral sequences that have been incorporated into the human genome over millions of years via integrations in germ-line cells. In this study, we investigated whether the expression of ERVs was associated with two different aspects of prostate cancer (PCa). First, Black American men have a higher incidence and poorer outcome of PCa compared to White men. We identified differences in ERV expression among prostate tumors between men of primarily African versus primarily European or Middle Eastern ancestry, which may be associated with differences in the mechanism of cancer progression in patients of these distinct ancestries. Second, we determined whether ERV expression might be correlated with the progression of disease, regardless of ancestry. We identified the ERV expression signatures that correlated with biochemical relapse among PCa patients of all ancestries, indicating that ERVs may be useful for identifying cancer patients at greatest risk of progression. The utility of ERV expression for studying cancer progression may extend to other cancers.

Abstract

Endogenous retroviruses (ERVs) are abundant, repetitive elements dispersed across the human genome and are implicated in various diseases. We investigated two potential roles for ERVs in prostate cancer (PCa). First, the PCa of Black Americans (BA) is diagnosed at an earlier median age and at a more advanced stage than the PCa of White Americans (WA). We used publicly available RNA-seq data from tumor-enriched samples of 27 BA and 65 WA PCa patients in order to identify 12 differentially expressed ERVs (p_adj < 0.1) and used a tissue microarray of the PCa cores from an independent set of BA and WA patients to validate the differential protein expression of one of these ERVs, ERV3-1 (p = 2.829 × 10⁻⁷). Second, we used 57 PCa tumors from patients of all ancestries from one hospital as a training set to identify the ERVs associated with time to biochemical relapse. A 29-ERV prognostic panel was then tested and validated on 35 separate PCa tumors from patients obtained in two different hospitals with a dramatic increase in prognostic power relative to clinical parameters alone (p = 7.4 × 10⁻¹¹). In summary, ERV RNA expression differences in the prostate tumors of patients of different ancestries may be associated with dissimilarities in the mechanism of cancer progression. In addition, the correlation of expression of certain ERVs in prostate tumors with the risk of biochemical relapse indicates a possible role for ERV expression in cancer progression.

Survival by race in men with chemotherapy-naive enzalutamide- or abiraterone-treated metastatic castration-resistant prostate cancer

BACKGROUND

Black men are more likely to be diagnosed with aggressive prostate cancer (PC) and die from PC than white men. However, black men with metastatic castration-resistant PC (mCRPC) had longer overall survival (OS) than white men when treated with certain agents in clinical trials. We analyzed claims data from the Veterans Health Administration (VHA) database to evaluate OS in black and white men treated with enzalutamide or abiraterone (novel hormonal therapy [NHT]) for chemotherapy-naïve mCRPC.

METHODS

Patients with mCRPC aged ≥18 years were identified in the VHA database by diagnosis codes, evidence of surgical/medical castration, and a prescription claim for enzalutamide or abiraterone after castration from April 2014-March 2017. Cox models assessed associations between race and OS. Unadjusted and multivariable analyses were performed on the entire population and subsets based on the type of therapy received (if any) after NHT.

RESULTS

In total, 2910 patients were identified (787 black, mean 71.7 years; 2123 white, mean 74.0 years). Median follow-up was 19.0 and 18.7 months in blacks and whites, respectively. Black men had better survival versus white men: hazard ratios (95% CIs) were 0.89 (0.790-0.996; P = 0.044) and 0.67 (0.592-0.758; P < 0.0001) in the unadjusted and multivariable models, respectively. Statistically significantly longer OS was seen in black versus white men regardless of subsequent treatment, including no subsequent treatment.

CONCLUSIONS

In the VHA, black men with chemotherapy-naïve mCRPC initiating NHT may have better outcomes than similarly treated white men.

African American Men have Increased Risk of Prostate Cancer Detection Despite Similar Rates of Anterior Prostatic Lesions and PI-RADS Grade on Multiparametric Magnetic Resonance Imaging

OBJECTIVE

To determine whether the frequency of anterior prostate lesions (APL) on multiparametric magnetic resonance imaging (mpMRI) prior to biopsy differed between African American (AA) and non-AA men and evaluate implications of race and tumor location for prostate cancer (PCa) detection.

METHODS

Patients from the Prospective Loyola University mpMRI (PLUM) Prostate Biopsy Cohort (January 2015-December 2020) without prior diagnosis of PCa were evaluated for APLs by race. Multivariable logistic regression models evaluated predictors of APLs and associations of APLs and race with detection of any PCa (grade group 1+) and clinically significant PCa (csPCa; grade group 2+). Additional stratified and propensity score matched analyses were conducted.

RESULTS

Of 1,239 men included, 190 (15.3%) were AA and 302 (24.4%) had at least one APL with no differences by race on multivariable analysis. While men with APLs were twice as likely to harbor PCa or csPCa, the unadjusted proportion of targeted biopsy-confirmed APL PCa (12.6% vs 12.0%) or csPCa (8.4% vs 8.9%) were similar for AA and non-AA men. AA men had higher risk of prostate cancer on targeted cores (OR 1.66 (95%CI 1.06 - 2.61), P = 0.026) which was independent of lesion location or PI-RADS.

CONCLUSION

AA men were found to have similar rates of APLs on mpMRI to non-AA men indicating access to mpMRI may mitigate some of the historical racial disparity based on lesion location. AA men have increased risk of PCa detection compared to non-AA men independent of anterior location or lesion grade on mpMRI reinforcing the importance of identifying genetic, biologic, and socioeconomic drivers.

[Outcomes of radical prostatectomy in patients with prostate cancer at the Aristide Le Dantec University Hospital]

Le but était d´évaluer les résultats carcinologiques de la prostatectomie radicale. Il s´agissait d´une étude rétrospective monocentrique au service d´urologie-andrologie de l´Hôpital Aristide Le Dantec de Dakar du 1^er juin 2010 au 31 mai 2016. Nous avons colligé 60 cas de prostatectomie radicale par voie rétropubienne associée à un curage ganglionnaire ilio-obturateur. Après la prostatectomie radicale (PR), le taux d’antigène prostatique spécifique (PSA) était indétectable (<0,1 ng/ml) chez 20 patients (33,3%). Onze malades (18,3%) qui avaient une récidive biochimique, ont une hormonothérapie complémentaire. Une réponse a été obtenue après instauration du traitement avec un taux de PSA total redevenu indétectable après un suivi de 8 mois. La durée moyenne de la survie globale était de 17,5 mois avec une médiane de 9,49. Le taux de survie globale cumulé à 1 an, 3 ans et 4 ans étaient respectivement de 42,4, 13,6 et 6,8%. La durée moyenne de la survie sans récidive était de 17,3 mois avec une médiane de survie sans récidive biochimique qui était de onze (11) mois. La durée moyenne de la survie spécifique était de 8,1 mois avec une médiane de 3 mois. Les marges de résection étaient positives chez sept (7) patients soit un taux de 11,6%. Quatre(4) patients avaient un envahissement ganglionnaire. La prostatectomie radicale indiquée dans quelques cas dans notre pratique, est une méthode thérapeutique efficiente avec de bons résultats carcinologiques.

Disparities in prostate cancer incidence and mortality rates: Solvable or not?

Prostate cancer (PCa) is recognized as a disease possessing not only great variation in its geographic and racial distribution but also tremendous variation in its potential to cause morbidity and death and it, therefore, ought not to be considered a homogenous disease entity. Morbidity and death from PCa are disproportionately higher in men of African ancestry (MAA) who are generally observed to have more aggressive disease and worse outcomes following treatment compared to men of European ancestry (MEA). The higher rates of PCa among MAA relative to MEA appear to be multifactorial and related to inherent differences in biological aggressiveness; a continued lack of awareness of the disease and methods of prevention; a lower prevalence of screen-detected PCa; comparatively lower access to quality healthcare as well as systemic and institutionalized disparities in the administration of optimal care to MAA in developed countries such as the United States of America where high-quality care is available. Even when access to quality healthcare is assured in equal access settings, it appears that MAA still have worse outcomes after PCa treatment stage-for-stage and grade-for-grade compared to MEA, suggesting that, inherent racial, ethnic and biological differences are paramount in predicting poor outcomes. This review has explored the different contributing factors to the current disparities in PCa incidence and mortality rates with emphasis on the incongruence in how research has been conducted in understanding the disease towards developing therapies.

Positive surgical margins at radical prostatectomy in the United States: Institutional variations and predictive factors

INTRODUCTION

Positive surgical margins (PSMs) are associated with treatment failure after radical prostatectomy (RP) for patients with prostate cancer (CaP). We investigated institutional variations in PSM after RP, as well as clinical and demographic factors predicting PSM.

PATIENTS AND METHODS

Patients undergoing RP for clinically localized CaP were identified in the National Cancer Database in 2010 to 2013 and clinicodemographics were recorded. Treating institution was defined as academic (AMC) or nonacademic medical centers (nAMC). The primary outcome was the PSM rate. Multivariable logistic regression and propensity matching with inverse probability treatment weighing were used to both compare outcomes between AMC and nAMC and to identify predictors of PSM following RP.

RESULTS

A total of 167,260 patients met our inclusion criteria. PSM rate was significantly lower in patients treated at AMC (13,435, 18.9%) compared with 22,145 (23.0%) in those treated at nAMC (P < 0.01). The difference between PSM rate in AMC and nAMC was more pronounced in lower volume centers while it was not significant in higher volume centers. On multivariable analysis, age, race, prostate-specific antigen (PSA), biopsy Gleason score, comorbidity profile, insurance type, income, and treatment facility were significantly associated with PSM rate.

CONCLUSION

PSM rates appear to be lower at AMC and higher volume facilities, which can potentially reflect institutional differences in surgical quality. In addition, we identified several socioeconomic and demographic factors that contribute to the likelihood of PSM following RP for localized CaP, suggesting potential systematic variation in the quality of surgical care. The cause of this variation warrants further investigation and evaluation.

Methionine-Homocysteine Pathway in African-American Prostate Cancer

African American (AA) men have a 60% higher incidence and two times greater risk of dying of prostate cancer (PCa) than European American men, yet there is limited insight into the molecular mechanisms driving this difference. To our knowledge, metabolic alterations, a cancer-associated hallmark, have not been reported in AA PCa, despite their importance in tumor biology. Therefore, we measured 190 metabolites across ancestry-verified AA PCa/benign adjacent tissue pairs (n = 33 each) and identified alterations in the methionine-homocysteine pathway utilizing two-sided statistical tests for all comparisons. Consistent with this finding, methionine and homocysteine were elevated in plasma from AA PCa patients using case-control (AA PCa vs AA control, methionine: P = .0007 and homocysteine: P < .0001), biopsy cohorts (AA biopsy positive vs AA biopsy negative, methionine: P = .0002 and homocysteine: P < .0001), and race assignments based on either self-report (AA PCa vs European American PCa, methionine: P = .001, homocysteine: P < .0001) or West African ancestry (upper tertile vs middle tertile, homocysteine: P < .0001; upper tertile vs low tertile, homocysteine: P = .002). These findings demonstrate reprogrammed metabolism in AA PCa patients and provide a potential biological basis for PCa disparities.

Variation in surgical treatment patterns for patients with prostate cancer in the United States: Do patients in academic hospitals fare better?

INTRODUCTION

With prostate cancer (CaP) screening, overtreatment of low-risk CaP remains a concern. We investigated the patterns of radical prostatectomy (RP) for pathologic insignificant (iCaP) and significant CaP (sCaP) as well as variations between academic and nonacademic hospitals.

PATIENTS AND METHODS

Patients undergoing RP for clinical T1c CaP were identified in the National Cancer Database between 2006 and 2013. The primary outcome was the trend of RP for insignificant prostate cancer (iCaP) and significant prostate cancer (sCaP) over the study period. The secondary outcome was to compare the RP rate in academic vs. nonacademic institutions. Univariable and multivariable analysis were utilized to evaluate the association between overtreatment and practice type. iCaP was defined as organ confined CaP with Gleason Score ≤6.

RESULTS

The total number of RP increased from 17,970 cases in 2006 to 25,324 in 2013. The RP rate decreased for iCaP from 39.9% to 19.8%, while increasing for sCaP from 18% to 27% over the study period. Patients undergoing RP in academic settings were less likely to have iCaP (odds ratio 0.88, 95% confidence interval 0.80-0.97). Caucasian race, private insurance, younger age, and treatment in the Eastern United States were associated with higher rates of iCaP at RP.

CONCLUSION

The rate of iCaP has declined over time in the United States for patients undergoing RP. Although RP in nonacademic setting was more likely to have iCaP on surgical pathology, this trend has been downward among practice types. Treatment appropriateness is an underrecognized, undermeasured, but increasingly important component of the high-value care discussion that warrants greater attention.

Prostate-specific antigen-based screening in Afro-Caribbean men: a survey of members of the Caribbean Urological Association

Objectives

To examine the attitudes, beliefs and practices of Caribbean urologists regarding prostate-specific antigen (PSA)-based screening in the Caribbean region particularly as it relates to Afro-Caribbean men.

Design

An Internet-based descriptive cross-sectional study using a standardised questionnaire designed to capture information on respondents' attitudes, beliefs and practices towards PSA-based screening was conducted using the online survey tool Survey Monkey among known urologists in the Caribbean, based on the complete mailing list of the membership of the Caribbean Urological Association.

Results

Thirty of the total population of 40 urologists (75%) from nine countries in the Caribbean completed the survey. Twelve (40%) were from Jamaica and eight (26.7%) were from Trinidad. Two-thirds (n = 20) of the urologists believed that PSA-based screening has positively impacted survival in their population and 76.7% (n = 23) supported the PSA-based screening in the Afro-Caribbean male. Seventy-eight percent believed that guidelines from other countries were not applicable to the Caribbean and 63% believed that a regional body should publish its own guidelines. Most supported yearly screening with the PSA and digital rectal examination beginning at age 40 for Afro-Caribbean men but opinion varied regarding PSA-based screening of Indo-Caribbean men. Respondents were unanimous in their belief that there should be an upper age limit for screening, 75 years old being the most commonly reported.

Conclusion

Most Caribbean urologists favour PSA-based screening in Afro-Caribbean men and recommend that Caribbean-specific guidelines need to be drafted.

Does Any Racial Disparity Exist in Oncologic Outcomes After Primary Cryotherapy for Prostate Cancer? A Matched-pair Comparative Analysis of the Cryo On-Line Data Registry

BACKGROUND

African-American (AA) men have the greatest incidence of and disease-specific mortality from prostate cancer of any racial group. Although encouraging oncologic and functional outcomes have been reported with prostate cancer cryotherapy, little is known about how ethnicity can potentially affect the oncologic outcomes of primary cryotherapy. We report the oncologic outcomes of primary cryotherapy in AA patients through a matched-pair analysis.

PATIENTS AND METHODS

A 1:2 (AA to non-AA) cohort of patients was designed using the Cryo-On-Line Data Registry. The 2 arms were matched for patient age, prostate-specific antigen level, Gleason score, and prostate volume. The oncologic outcome was defined in terms of the biochemical recurrence (BCR) rates after primary cryoablation using Phoenix criteria. The results of "for-cause" post-treatment biopsies and the BCR-free survival rates were also analyzed between the 2 groups.

RESULTS

The 1:2 cohort of AA and non-AA men in the present study included 109 and 218 men, respectively. Their median age (69 vs. 71 years; P = .71), median prostate-specific antigen level (6.5 vs. 6.8 ng/mL; P = .95), median prostate volume (32 vs. 30 cm³; P = .31), Gleason score distribution (P = .97), and prostate cancer risk group (P = .12) were similar statistically. The median postoperative follow-up period was also comparable between the 2 groups (AA, 32 months vs. non-AA, 27 months; P = .52). The BCR rates were similar between the AA and non-AA men (14% vs. 17%; P = .52). Likewise, the rate of positive "for-cause" prostate biopsy findings was similar between the 2 groups (AA vs. non-AA, 25% vs. 36%; P = .44). Furthermore, the 5-year biochemical relapse-free survival rates were comparable for the AA and non-AA patients (74% vs. 71%; P = .37).

CONCLUSION

When matched for tumor characteristics, cryotherapy as a treatment modality for primary, clinically localized prostate cancer offers men of African-American descent similar oncologic outcomes to those of non-AA men.

Detection of prostate cancer using magnetic resonance imaging/ultrasonography image-fusion targeted biopsy in African-American men

OBJECTIVE

To assess the diagnostic yield of targeted prostate biopsy in African-American (A-A) men using image fusion of multi-parametric magnetic resonance imaging (mpMRI) with real-time transrectal ultrasonography (US).

PATIENTS AND METHODS

We retrospectively analysed 661 patients (117 A-A and 544 Caucasian) who had mpMRI before biopsy and then underwent MRI/US image-fusion targeted biopsy (FTB) between October 2012 and August 2015. The mpMRIs were reported on a 5-point Likert scale of suspicion. Clinically significant prostate cancer (CSPC) was defined as biopsy Gleason score ≥7.

RESULTS

After controlling for age, prostate-specific antigen level and prostate volume, there were no significant differences between A-A and Caucasian men in the detection rate of overall cancer (35.0% vs 34.2%, P = 0.9) and CSPC (18.8% vs 21.7%, P = 0.3) with MRI/US FTB. There were no significant differences between the races in the location of dominant lesions on mpMRI, and in the proportion of 5-point Likert scoring. In A-A men, MRI/US FTB from the grade 4-5 lesions outperformed random biopsy in the detection rate of overall cancer (70.6% vs 37.2%, P = 0.003) and CSPC (52.9% vs 12.4%, P < 0.001). MRI/US FTB outperformed random biopsy in cancer core length (5.0 vs 2.4 mm, P = 0.001), in cancer rate per core (24.9% vs 6.8%, P < 0.001), and in efficiency for detecting one patient with CSPC (mean number of cores needed 13.3 vs 81.9, P < 0.001), respectively.

CONCLUSIONS

Our key finding confirms a lack of racial difference in the detection rate of overall prostate cancers and CSPC with MRI/US FTB between A-A and Caucasian men. MRI/US FTB detected more CSPC using fewer cores compared with random biopsy.

Influence of In Utero Maternal and Neonate Factors on Cord Blood Leukocyte Telomere Length: Clues to the Racial Disparity in Prostate Cancer?

Background. Modifiable factors in adulthood that explain the racial disparity in prostate cancer have not been identified. Because racial differences in utero that may account for this disparity are understudied, we investigated the association of maternal and neonate factors with cord blood telomere length, as a cumulative marker of cell proliferation and oxidative damage, by race. Further, we evaluated whether cord blood telomere length differs by race. Methods. We measured venous umbilical cord blood leukocyte relative telomere length by qPCR in 38 black and 38 white full-term male neonates. Using linear regression, we estimated geometric mean relative telomere length and tested for differences by race. Results. Black mothers were younger and had higher parity and black neonates had lower birth and placental weights. These factors were not associated with relative telomere length, even after adjusting for or stratifying by race. Relative telomere length in black (2.72) and white (2.73) neonates did not differ, even after adjusting for maternal or neonate factors (all p > 0.9). Conclusions. Maternal and neonate factors were not associated with cord blood telomere length, and telomere length did not differ by race. These findings suggest that telomere length at birth does not explain the prostate cancer racial disparity.

Outcome of radical retropubic prostatectomy at the Lagos State University Teaching Hospital

Background:

Prostate cancer is the most commonly diagnosed cancer in men in Nigeria and most cases present when the disease is already in an advanced stage. Radical prostatectomy for early prostate cancer is therefore not a commonly performed operation by urologists in Nigeria. We have had training and significant experience in radical retropubic prostatectomy. We, therefore, report the outcome of our initial experience.

Materials and Methods:

We review the record of men with early prostate cancer who had radical retropubic prostatectomy in our institution from 2007 to 2015.

Results:

There were 34 men who had radical retropubic prostatectomy in the 8-year period of review. The youngest and oldest patients were aged 50 and 71 years, respectively. The mean age was 64.2 years. All the patients were diagnosed following 12-core ultrasound-guided transrectal prostate biopsy for elevated serum prostate specific antigen (PSA). The mean serum PSA was 15.3 (range 8.5-100.3) ng/ml. The disease was pT1, pT2, and pT3 in 6, 20, and 8 patients respectively. General anesthesia was employed in 28 (82.4%) patients and combined epidural and subarachnoid block anesthesia for 6 (17.6%) patients. The total duration of operation was 128-252 min (mean = 160 min). No blood transfusion was given in 5 (14.7%) patients while each of the remaining 29 (85.3%) patients had 2-5 units of blood intra- or post-operatively. There was no perioperative mortality. Complications include operation-induced erectile dysfunction in 12 (35.3%), major urinary incontinence in 1 (2.9%), lymphocele in 2 (5.9%), and reoperation due to anastomotic leak and right ureteric injury in 1 (2.9%). After a median follow-up of 42 months, disease recurrence has occurred in 3 (8.8%) patients 1 (2.9%) of whom has died of diabetic renal failure.

Conclusion:

Radical prostatectomy can be safely performed in men with early prostate cancer in Nigeria and should be offered to suitable patients.

Pathological and Biochemical Outcomes among African-American and Caucasian Men with Low Risk Prostate Cancer in the SEARCH Database: Implications for Active Surveillance Candidacy

PURPOSE

Racial disparities in the incidence and risk profile of prostate cancer at diagnosis among African-American men are well reported. However, it remains unclear whether African-American race is independently associated with adverse outcomes in men with clinical low risk disease.

MATERIALS AND METHODS

We retrospectively analyzed the records of 895 men in the SEARCH (Shared Equal Access Regional Cancer Hospital) database in whom clinical low risk prostate cancer was treated with radical prostatectomy. Associations of African-American and Caucasian race with pathological biochemical recurrence outcomes were examined using chi-square, logistic regression, log rank and Cox proportional hazards analyses.

RESULTS

We identified 355 African-American and 540 Caucasian men with low risk tumors in the SEARCH cohort who were followed a median of 6.3 years. Following adjustment for relevant covariates African-American race was not significantly associated with pathological upgrading (OR 1.33, p = 0.12), major upgrading (OR 0.58, p = 0.10), up-staging (OR 1.09, p = 0.73) or positive surgical margins (OR 1.04, p = 0.81). Five-year recurrence-free survival rates were 73.4% in African-American men and 78.4% in Caucasian men (log rank p = 0.18). In a Cox proportional hazards analysis model African-American race was not significantly associated with biochemical recurrence (HR 1.11, p = 0.52).

CONCLUSIONS

In a cohort of patients at clinical low risk who were treated with prostatectomy in an equal access health system with a high representation of African-American men we observed no significant differences in the rates of pathological upgrading, up-staging or biochemical recurrence. These data support continued use of active surveillance in African-American men. Upgrading and up-staging remain concerning possibilities for all men regardless of race.

Prostate cancer in men of African origin

Men of African origin are disproportionately affected by prostate cancer: prostate cancer incidence is highest among men of African origin in the USA, prostate cancer mortality is highest among men of African origin in the Caribbean, and tumour stage and grade at diagnosis are highest among men in sub-Saharan Africa. Socioeconomic, educational, cultural, and genetic factors, as well as variations in care delivery and treatment selection, contribute to this cancer disparity. Emerging data on single-nucleotide-polymorphism patterns, epigenetic changes, and variations in fusion-gene products among men of African origin add to the understanding of genetic differences underlying this disease. On the diagnosis of prostate cancer, when all treatment options are available, men of African origin are more likely to choose radiation therapy or to receive no definitive treatment than white men. Among men of African origin undergoing surgery, increased rates of biochemical recurrence have been identified. Understanding differences in the cancer-survivorship experience and quality-of-life outcomes among men of African origin are critical to appropriately counsel patients and improve cultural sensitivity. Efforts to curtail prostate cancer screening will likely affect men of African origin disproportionately and widen the racial disparity of disease.

Prostate cancer trends in Barbados: An analysis of the Barbados Urologic Diseases Survey database

OBJECTIVES

To describe the burden and trend of prostate cancer (CaP) in the Caribbean island of Barbados.

METHODS

All urologic pathology reports in Barbados between 1990 and 2009 were entered into the Barbados Urologic Diseases Survey (BUDS) database. All new cases of CaP were identified and the database was used to assess trends in CaP epidemiology over the study period.

RESULTS

3066 new cases of CaP were identified between 1990 and 2009. The world age-standardized rate increased steadily from 71.8 (95% CI 57.8-88.4) per 100,000 in 1990 to 112.4 (95% CI 94.0-133.7) per 100,000 in 2009, with a peak rate of 148.9 (95% CI 127.0-172.8) in 2004. The cumulative risk up to 74 years of age also increased from 11.1% in 1990 to 23.8% in 2009 with a peak of 29.9% in 2004. The mean age at diagnosis decreased from 73.1 years in 1990 to a nadir of 66.2 years in 2009. The rate of high-grade cancer (Gleason score ≥ 8) and intermediate-grade cancer (Gleason score=7) at presentation rose between 2000 and 2009 while the rate of low-grade cancer (Gleason score ≤ 6) decreased.

CONCLUSIONS

Barbados suffers an unusually high burden of CaP with a trend towards more aggressive disease over the last decade. The results are important as they highlight the utility of the BUDS initiative in epidemiologic evaluation, but should be looked at cautiously due to a lack of specific details regarding screening practices in this population.

Rural-urban differences in the clinico-pathologic profiles of Jamaican men with prostate cancer

Background

Prostate cancer causes the highest number of cancer-related deaths in Jamaican men. It is not known whether rural-dwelling men present with worse disease than urban-dwelling men at initial presentation. Since rural and urban-dwelling Jamaicans are predominantly of African descent and generally similar in respect of racial composition, if any significant variation in initial presentation were found, it would suggest that these are likely due to differences in awareness, access to care, and screening patterns.

Methods

The medical records of rural and urban-dwelling patients with prostate cancer were compared. Patients’ age at presentation, initial prostate-specific antigen level, digital rectal examination findings, biopsy Gleason scores and initial treatment received were compared using bivariate and logistic regression analyses.

Results

In unadjusted analyses rural-dwelling men were older compared to urban-dwelling men (72 years versus 68.5 years, p = 0.035), had higher median PSA values (22.9 ng/ml versus 18 ng/ml, p = 0.001), higher local tumour stage (65.2 % versus 34.8 % T3 disease; 73.7 % versus 26.3 % T4 disease; p = 0.005), higher mean Gleason scores (p = 0.048) and more non-curative initial treatments. Local tumour stage was the only statistically significant difference between rural and urban-dwelling men in logistic regression analysis with rural-dwelling men having a 70 % higher risk of locally-advanced disease (OR = 1.70, 95 % CI: 1.03-2.79; p = 0.038).

Conclusion

Rural-dwelling men presented with more advanced prostate cancer compared to urban-dwelling men. As both rural and urban-dwelling men are of predominant African descent it is likely that these differences are due to differences in access to care, screening practice and awareness of the disease.

Analysis of Prostate Cancer Susceptibility Variants in South African Men: Replicating Associations on Chromosomes 8q24 and 10q11

Genome-wide association studies (GWAS) have implicated single nucleotide polymorphisms (SNPs) on chromosomes 2p15, 6q25, 7p15.2, 7q21, 8q24, 10q11, 10q26, 11q13, 17q12, 17q24, 19q13, and Xp11, with prostate cancer (PCa) susceptibility and/or tumour aggressiveness, in populations of African, European, and Asian ancestry. The objective of this study was to confirm these associations in South African Mixed Ancestry and White men. We evaluated 17 prioritised GWAS SNPs in South African cases (331 Mixed Ancestry and 155 White) and controls (178 Mixed Ancestry and 145 White). The replicated SNP associations for the different South African ethnic groups were rs7008482 (8q24) (p = 2.45 × 10⁻⁵), rs6983267 (8q24) (p = 4.48 × 10⁻⁷), and rs10993994 (10q11) (p = 1.40 × 10⁻³) in Mixed Ancestry men and rs10993994 (p = 1.56 × 10⁻⁹) in White men. No significant associations were observed for the analyses stratified by disease aggressiveness in the individual and the combined population group analysis. The present study demonstrates that a number of known PCa susceptibility variants may contribute to disease susceptibility in South African men. Larger genetic investigations extended to other South African population groups are warranted to confirm the role of these and other SNPs in disease susceptibility.

Delay from biopsy to radical prostatectomy influences the rate of adverse pathologic outcomes

BACKGROUND

We sought to determine maximum wait times between biopsy diagnosis and surgery for localized prostate cancer, beyond which the rate of adverse pathologic outcomes is increased.

METHODS

We retrospectively reviewed 4,610 patients undergoing radical prostatectomy between 1990 and 2011. Patients were stratified by biopsy Gleason score and PSA value. For each stratification, χ2 analysis was used to determine the smallest 15-day multiple of surgical delay (e.g., 15, 30, 45…180 days) for which adverse pathologic outcomes were significantly more likely after the time interval than before. Adverse outcomes were defined as positive surgical margins, upgrading from biopsy, upstaging, seminal vesicle invasion, or positive lymph nodes.

RESULTS

Two thousand two hundred twelve patients met inclusion criteria. Median delay was 64 days (mean 76, SD 47). One thousand six hundred seventy-five (75.7%), 537 (24.3%), and 60 (2.7%) patients had delays of <=90, >90, and >180 days, respectively. Twenty-six percent were upgraded on final pathology and 23% were upstaged. The positive surgical margin rate was 24.2% and the positive lymph node rate was 1.1%. Significant increases in the proportion of adverse pathological outcomes were found beyond 75 days in the overall cohort (P = 0.03), 150 days for patients with Gleason <=6, and PSA 0-10 (P = 0.038), 60 days for patients with Gleason 7 and PSA >20 (P = 0.032), and 30 days for patients with Gleason 8-10 and PSA 11-20 (0.041).

CONCLUSION

In low-risk disease, there is a considerable but not unlimited surgical delay which will not adversely impact the rate of adverse pathologic features found. In higher risk disease, this time period is considerably shorter.

A Population-Based Study of Men With Low-Volume Low-Risk Prostate Cancer: Does African-American Race Predict for More Aggressive Disease?

BACKGROUND

Because of recent reports that suggested more pathologically aggressive disease in African-American (AA) men, we sought to compare pathologic features between AA and Caucasian-American men with low-risk, low-volume prostate cancer.

MATERIALS AND METHODS

We analyzed the Surveillance, Epidemiology, and End Results database for pathologic differences based on race. Data on all men who were diagnosed between 2010 and 2011 with prostate cancer, T1cN0M0, Gleason score of 6 (3+3), prostate-specific antigen < 10 ng/mL, via a 12-core biopsy and had ≤ 2 positive samples, and underwent radical prostatectomy were abstracted. Univariate and multivariate logistic regression were performed to detect predictors for adverse pathology, which was primarily defined as pT2 and Gleason ≥ 4+3, or pT3a and Gleason 3+3 with positive margins, pT3a and Gleason ≥ 3+4, or pT3b-pT4 with any Gleason score.

RESULTS

There were 1794 men who met the target study criteria. AA men were a median of 3 years younger (P < .001), and were more likely to have 2 positive cores (P = .02). However, there were no statistically significant differences between Caucasian and AA men regarding pathologic Gleason score (P = .99), pathologic extent of disease (P = .34), margins (P = .43), Cancer of the Prostate Risk Assessment score (P = .56), or adverse features (P = .45). On multivariate analysis, there were no differences between AA and Caucasian men with regard to adverse pathologic features (odds ratio, 1.43; 95% confidence interval, 0.87-1.24; P = .16).

CONCLUSION

In the absence of definitive data to support a more aggressive natural history of very low risk prostate cancer in AA men, these data support continued use of active surveillance in this population.

Current state of prostate cancer treatment in Jamaica

Prostate cancer is the commonest cancer in Jamaica as well as the leading cause of cancer-related deaths. One report suggested that Jamaica has the highest incidence rate of prostate cancer in the world, with an age-standardised rate of 304/100,000 per year. The Caribbean region is reported to have the highest mortality rate of prostate cancer worldwide. Prostate cancer accounts for a large portion of the clinical practice for health-care practitioners in Jamaica. The Jamaica Urological Society is a professional body comprising 19 urologists in Jamaica who provide most of the care for men with prostate cancer in collaboration with medical oncologists, radiation oncologists, and a palliative care physician. The health-care system is structured in two tiers in Jamaica: public and private. The urologist-to-patient ratio is high, and this limits adequate urological care. Screening for prostate cancer is not a national policy in Jamaica. However, the Jamaica Urological Society and the Jamaica Cancer Society work synergistically to promote screening as well as to provide patient education for prostate cancer. Adequate treatment for localised prostate cancer is available in Jamaica in the forms of active surveillance, nerve-sparing radical retropubic prostatectomy, external beam radiation, and brachytherapy. However, there is a geographic maldistribution of centres that provide prostate cancer treatment, which leads to treatment delays. Also, there is difficulty in affording some treatment options in the private health-care sectors. Androgen deprivation therapy is available for treatment of locally advanced and metastatic prostate cancer and is subsidised through a programme called the National Health Fund. Second-line hormonal agents and chemotherapeutic agents are available but are costly to most of the population. The infrastructure for treatment of prostate cancer in Jamaica is good, but it requires additional technological advances as well as additional specialist services.

Impact of race in a predominantly African-American population of patients with low/intermediate risk prostate cancer undergoing radical prostatectomy within an equal access care institution

PURPOSE

To study the impact of race in an equal access care institution with a predominantly African-American (AA) population.

METHODS

We retrospectively reviewed data from 222 men with low risk (LR) or intermediate risk (IR) prostate cancer who underwent radical prostatectomy at the New York Harbor VA between 2003 and 2011. Biochemical relapse, distant control, and prostate cancer-specific survival were analyzed using the Kaplan-Meier method and compared using the log-rank test. Univariate and multivariate Cox regression modeling was performed to determine the impact of covariates on biochemical outcome.

RESULTS

Most patients (65.3 %) were AA. The median follow-up was 58 months, and 89.6 % of patients were followed for a minimum of 2 years after their surgery. Analyzing the whole cohort, the biochemical control was improved in Caucasian patients compared with AA (90.2 vs. 75.4 %, p = 0.008). On subgroup analysis, for IR disease, this difference was no longer significant, 80.5 % for Caucasians versus 69.8 % for AA (p = 0.36). However, for LR disease, the 5-year biochemical control remained significantly improved for Caucasians compared with AA, with a 5-year biochemical control of 97.6 versus 81.7 %, p = 0.006. On multivariate analysis, AA race was a significant predictor for biochemical recurrence (HR 2.69, 95 % CI 1.27-5.65, p = 0.009). There were no differences between the two groups regarding distant control (p = 0.14) or prostate cancer-specific survival (p = 0.29).

CONCLUSIONS

In this predominant AA population with equal access to medical care, AA race is an independent predictor of biochemical recurrence after prostatectomy in men with LR or IR prostate cancer.

Preferential autoimmune response in prostate cancer to cyclin B1 in a panel of tumor-associated antigens

Previous studies have demonstrated that sera from patients with prostate cancer (PCa) contain autoantibodies that react with tumor-associated antigens (TAAs). Autoantibodies to cyclin B1 and fourteen other TAAs were detected by enzyme-linked immunosorbent assay (ELISA) and Western blotting in 464 sera from patients with PCa, benign prostatic hyperplasia (BPH), and other controls. Autoantibodies to cyclin B1 were detected in 31.0% of sera from randomly selected patients with PCa versus 4.8% in sera with BPH. In the further analysis, 31.4% of sera from PCa patients at the early stage contained anti-cyclin B1 autoantibody, and even 29.4% of patients who had normal prostate-specific antigen (PSA) levels in their serum samples were observed anti-cyclin B1 positive. The cumulative positive rate of autoantibodies against seven selected TAAs (cyclin B1, survivin, p53, DFS70/LEDGFp75, RalA, MDM2, and NPM1) in PCa reached 80.5%, significantly higher than that in normal control sera. In summary, autoantibody to cyclin B1 might be a potential biomarker for the immunodiagnosis of early stage PCa, especially useful in patients with normal PSA level. This study further supports the hypothesis that a customized TAA array can be used for enhancing anti-TAA autoantibody detection, and it may constitute a promising and powerful tool for immunodiagnosis of PCa.

Racial and socioeconomic disparities in presentation and outcomes of well-differentiated thyroid cancer

CONTEXT

Racial/ethnic minorities suffer disproportionate morbidity and mortality from chronic diseases.

OBJECTIVE

Our objective was to assess racial and socioeconomic status (SES) disparities in well-differentiated thyroid cancer (WDTC) patients.

DESIGN AND PARTICIPANTS

We conducted a retrospective cohort study on 25 945 patients with WDTC (1999-2008) from the California Cancer Registry (57% white, 4% black, 24% Hispanic, and 15% Asian-Pacific Islander [API]).

MAIN OUTCOMES

We evaluated effect of race and SES variables on stage of cancer presentation and overall/disease-specific survival.

RESULTS

Significant differences in stage of presentation between all racial groups were found (P<.001), with minority groups presenting with a higher percentage of metastatic disease as compared with white patients (black, odds ratio [OR]=1.36 with confidence interval [CI] 1.01-1.84; Hispanic, OR=1.89 [CI, 1.62-2.21], API, OR=1.82 [CI, 1.54-2.15]). Hispanic (OR=1.59, [CI, 1.48-1.72]) and API (OR=1.32 [1.22-1.44]) patients also presented with higher odds of regional disease. Patients with the lowest SES presented with metastatic disease more often than those with the highest SES (OR=1.45 [CI, 1.16-1.82]). Those that were poor/uninsured and/or with Medicaid insurance had higher odds of presenting with metastatic disease as compared with those with private insurance (OR=2.41, [CI, 2.10-2.77]). Unadjusted overall survival rates were higher among API and Hispanic patients and lower among black patients (P<.001 vs white patients). Adjusted overall survival also showed a survival disadvantage for black patients (hazard ratio=1.4, [CI, 1.10-1.73]) and survival advantage for API patients (hazard ratio=0.83, [CI, 0.71-0.97]). In disease-specific survival analyses, when only those patients with metastatic disease were analyzed separately, black patients again had the lowest survival rates, and Hispanic/API patients had the highest survival rates (P<.04).

CONCLUSION

Black patients and those with low SES have worse outcomes for thyroid cancer. API and Hispanic patients may have a protective effect on survival despite presenting with more advanced disease.

African American men with very low-risk prostate cancer exhibit adverse oncologic outcomes after radical prostatectomy: should active surveillance still be an option for them?

PURPOSE

Active surveillance (AS) is a treatment option for men with very low-risk prostate cancer (PCa); however, favorable outcomes achieved for men in AS are based on cohorts that under-represent African American (AA) men. To explore whether race-based health disparities exist among men with very low-risk PCa, we evaluated oncologic outcomes of AA men with very low-risk PCa who were candidates for AS but elected to undergo radical prostatectomy (RP).

PATIENTS AND METHODS

We studied 1,801 men (256 AA, 1,473 white men, and 72 others) who met National Comprehensive Cancer Network criteria for very low-risk PCa and underwent RP. Presenting characteristics, pathologic data, and cancer recurrence were compared among the groups. Multivariable modeling was performed to assess the association of race with upgrading and adverse pathologic features.

RESULTS

AA men with very low-risk PCa had more adverse pathologic features at RP and poorer oncologic outcomes. AA men were more likely to experience disease upgrading at prostatectomy (27.3% v 14.4%; P < .001), positive surgical margins (9.8% v 5.9%; P = .02), and higher Cancer of the Prostate Risk Assessment Post-Surgical scoring system (CAPRA-S) scores. On multivariable analysis, AA race was an independent predictor of adverse pathologic features (odds ratio, [OR], 3.23; P = .03) and pathologic upgrading (OR, 2.26; P = .03).

CONCLUSION

AA men with very low-risk PCa who meet criteria for AS but undergo immediate surgery experience significantly higher rates of upgrading and adverse pathology than do white men and men of other races. AA men with very low-risk PCa should be counseled about increased oncologic risk when deciding among their disease management options.

Pathological examination of radical prostatectomy specimens in men with very low risk disease at biopsy reveals distinct zonal distribution of cancer in black American men

PURPOSE

Of men with very low risk prostate cancer at biopsy recent evidence shows that black American men are at greater risk for adverse oncologic outcomes after radical prostatectomy. We studied radical prostatectomy specimens from black and white men at very low risk to determine whether there are systematic pathological differences.

MATERIALS AND METHODS

Radical prostatectomy specimens were evaluated in men with National Comprehensive Cancer Network® (NCCN) very low risk prostate cancer. At diagnosis all men underwent extended biopsy sampling (10 or more cores) and were treated in the modern Gleason grade era. We analyzed tumor volume, grade and location in 87 black and 89 white men. For each specimen the dominant nodule was defined as the largest tumor with the highest grade.

RESULTS

Compared to white men, black men were more likely to have significant prostate cancer (61% vs 29%), Gleason 7 or greater (37% vs 11%, each p <0.001) and a volume of greater than 0.5 cm(3) (45% vs 21%, p = 0.001). Dominant nodules in black men were larger (median 0.28 vs 0.13 cm(3), p = 0.002) and more often anterior (51% vs 29%, p = 0.003). In men who underwent pathological upgrading the dominant nodule was also more frequently anterior in black than in white men (59% vs 0%, p = 0.001).

CONCLUSIONS

Black men with very low risk prostate cancer at diagnosis have a significantly higher prevalence of anterior cancer foci that are of higher grade and larger volume. Enhanced imaging or anterior zone sampling may detect these significant anterior tumors, improving the outcome in black men considering active surveillance.

Comparison of oncologic outcomes after radical prostatectomy in men diagnosed with prostate cancer with PSA levels below and above 4 ng/mL

PURPOSE

To assess whether the PSA level (threshold 4 ng/mL) is a prognostic factor in biochemical recurrence-free survival in men with prostate cancer (PCa) with an initial PSA level <10 ng/mL who underwent robotic-assisted laparoscopic radical prostatectomy (RARLP).

METHODS

We prospectively recruited data for consecutive patients treated by RARLP for PCa with an initial PSA level below 10 ng/mL between 2003 and 2011 at our institution. We divided the population into two groups: patients with a PSA level below 4 ng/mL (G1; n = 53) and patients with a PSA level between 4 and 10 ng/mL (G2; n = 371). Biochemical recurrence was defined as a single increase in PSA greater than 0.2 ng/mL after surgery. Multivariate analysis was used to assess prognostic factors of recurrence-free survival.

RESULTS

Overall, 424 patients were included, and the median age was 62 (58-67) years. The median PSA was 5.8 ng/mL (4.8-7.7 ng/mL). Overall, 6 patients from G1 and 34 patients from G2 experienced a biochemical recurrence. Overall, the 5-year recurrence-free survival rate was 86.6 %. The PSA level at diagnosis (under or over 4 ng/mL) was not significantly linked to recurrence-free survival (HR = 0.59, p = 0.25). However, positive margins and a Gleason score >7 on the specimen were significantly linked to recurrence-free survival with respective hazard ratios of 4.30 (p < 0.0001) and 6.18 (p < 0.0001), respectively.

CONCLUSION

A PSA level <4 ng/mL alone appears to be obsolete as a cut-off to define a population of men likely to have indolent disease.