Salvage Therapy for Prostate Cancer: AUA/ASTRO/SUO Guideline Part II: Treatment Delivery for Non-metastatic Biochemical Recurrence After Primary Radical Prostatectomy

PURPOSE

The summary presented herein covers recommendations on salvage therapy for recurrent prostate cancer intended to facilitate care decisions and aid clinicians in caring for patients who have experienced a recurrence following prior treatment with curative intent. This is Part II of a three-part series focusing on treatment delivery for non-metastatic biochemical recurrence (BCR) after primary radical prostatectomy (RP). Please refer to Part I for discussion of treatment decision-making and Part III for discussion of evaluation and management of recurrence after radiotherapy (RT) and focal therapy, regional recurrence, and oligometastasis.

MATERIALS AND METHODS

The systematic review that informs this Guideline was based on searches in Ovid MEDLINE (1946 to July 21, 2022), Cochrane Central Register of Controlled Trials (through August 2022), and Cochrane Database of Systematic Reviews (through August 2022). Update searches were conducted on July 26, 2023. Searches were supplemented by reviewing electronic database reference lists of relevant articles.

RESULTS

In a collaborative effort between AUA, ASTRO, and SUO, the Salvage Therapy for Prostate Cancer Panel developed evidence- and consensus-based guideline statements to provide guidance for the care of patients who experience BCR after initial definitive local therapy for clinically localized disease.

CONCLUSIONS

Optimizing and personalizing the approach to salvage therapy remains an ongoing area of work in the field of genitourinary oncology and represents an area of research and clinical care that requires well-coordinated, multi-disciplinary efforts.

Chronic Glucocorticoid Use and Risk for Advanced Prostate Cancer at Presentation: A SEER-Medicare Cohort Study

BACKGROUND

Examine the relationship between exposure to systemic glucocorticoids (steroids) and advanced prostate cancer (PCa) at presentation. Prior work suggested that steroid use may be associated with increased PCa risk.

MATERIALS AND METHODS

We queried the linked SEER-Medicare database (2004-2015) to identify PSA screened patients diagnosed with PCa. Criteria for screening included a PSA lab test or DRE exam in both the 12 month and 13 to 36 month periods prior to diagnosis of PCa. Steroid exposure was determined using Medicare Part D and groups were divided based on duration of use in the 3 years prior to diagnosis: controls with no exposure, <30 days, 30 days - 1 year, 1 to 2 years, and >2+ years. Advanced PCa was defined as systemic metastases or regional lymph node metastasis at presentation. Risk estimates for advanced PCa at presentation for steroid exposure groups vs. controls were assessed with univariable and multivariable logistic regression models.

RESULTS

We identified 22,920 PSA screened patients diagnosed with PCa of which 29% used glucocorticoids in the exposure period. The mean (SD) duration for glucocorticoid use (in days) among all steroid users was 76.7 days (192.1). On univariable and multivariable analyses, > 2 years of steroid exposure was associated with significantly increased risk for advanced PCa (OR 2.06, 95% CI 1.35-3.14 and OR 1.74, 95% CI 1.12-2.69, respectively).

CONCLUSION

In this population-based PSA-screened cohort, prolonged steroid use was associated with increased risk of advanced PCa at diagnosis. With the widespread use of glucocorticoids, it is important to consider the role steroids may play in PCa pathogenesis.

Salvage Therapy for Prostate Cancer: AUA/ASTRO/SUO Guideline Part III: Salvage Therapy After Radiotherapy or Focal Therapy, Pelvic Nodal Recurrence and Oligometastasis, and Future Directions

PURPOSE

The summary presented herein covers recommendations on salvage therapy for recurrent prostate cancer intended to facilitate care decisions and aid clinicians in caring for patients who have experienced a recurrence following prior treatment with curative intent. This is Part III of a three-part series focusing on evaluation and management of suspected non-metastatic recurrence after radiotherapy (RT) and focal therapy, evaluation and management of regional recurrence, management for molecular imaging metastatic recurrence, and future directions. Please refer to Part I for discussion of treatment decision-making and Part II for discussion of treatment delivery for non-metastatic biochemical recurrence (BCR) after radical prostatectomy (RP).

MATERIALS AND METHODS

The systematic review that informs this Guideline was based on searches in Ovid MEDLINE (1946 to July 21, 2022), Cochrane Central Register of Controlled Trials (through August 2022), and Cochrane Database of Systematic Reviews (through August 2022). Update searches were conducted on July 26, 2023. Searches were supplemented by reviewing electronic database reference lists of relevant articles.

RESULTS

In a collaborative effort between AUA, ASTRO, and SUO, the Salvage Therapy for Prostate Cancer Guideline Panel developed evidence- and consensus-based guideline statements to provide guidance for the care of patients who experience BCR after initial definitive local therapy for clinically localized disease.

CONCLUSIONS

Continuous and deliberate efforts for multidisciplinary care in prostate cancer will be required to optimize and improve the oncologic and functional outcomes of patients treated with salvage therapies in the future.

Salvage Therapy for Prostate Cancer: AUA/ASTRO/SUO Guideline Part I: Introduction and Treatment Decision-Making at the Time of Suspected Biochemical Recurrence after Radical Prostatectomy

PURPOSE

The summary presented herein covers recommendations on salvage therapy for recurrent prostate cancer intended to facilitate care decisions and aid clinicians in caring for patients who have experienced a recurrence following prior treatment with curative intent. This is Part I of a three-part series focusing on treatment decision-making at the time of suspected biochemical recurrence (BCR) after radical prostatectomy (RP). Please refer to Part II for discussion of treatment delivery for non-metastatic BCR after RP and Part III for discussion of evaluation and management of recurrence after radiotherapy (RT) and focal therapy, regional recurrence, and oligometastasis.

MATERIALS AND METHODS

The systematic review that informs this Guideline was based on searches in Ovid MEDLINE (1946 to July 21, 2022), Cochrane Central Register of Controlled Trials (through August 2022), and Cochrane Database of Systematic Reviews (through August 2022). Update searches were conducted on July 26, 2023. Searches were supplemented by reviewing electronic database reference lists of relevant articles.

RESULTS

In a collaborative effort between AUA, ASTRO, and SUO, the Salvage Therapy for Prostate Cancer Panel developed evidence- and consensus-based statements to provide guidance for the care of patients who experience BCR after initial definitive local therapy for clinically localized disease.

CONCLUSIONS

Advancing work in the area of diagnostic tools (particularly imaging), biomarkers, radiation delivery, and biological manipulation with the evolving armamentarium of therapeutic agents will undoubtedly present new opportunities for patients to experience long-term control of their cancer while minimizing toxicity.

Isolating the Drivers of Racial Inequities in Prostate Cancer Treatment

BACKGROUND

Black individuals in the United States are less likely than White individuals to receive curative therapies despite a 2-fold higher risk of prostate cancer death. While research has described treatment inequities, few studies have investigated underlying causes.

METHODS

We analyzed a cohort of 40,137 Medicare beneficiaries (66 and older) linked to the Surveillance Epidemiology and End Results (SEER) cancer registry who had clinically significant, non-metastatic (cT1-4N0M0, grade group 2-5) prostate cancer (diagnosed 2010-2015). Using the Kitagawa-Oaxaca-Blinder decomposition, we assessed the contributions of patient health and health care delivery on the racial difference in localized prostate cancer treatments (radical prostatectomy or radiation). Patient health consisted of comorbid diagnoses, tumor characteristics, SEER site, diagnosis year, and age. Health care delivery was captured as a prediction model with these health variables as predictors of treatment, reflecting current treatment patterns.

RESULTS

A total of 72.1% and 78.6% of Black and White patients received definitive treatment, respectively, a difference of 6.5 percentage points. An estimated 15% [95% confidence interval (CI): 6-24] of this treatment difference was explained by measured differences in patient health, leaving the remaining estimated 85% (95% CI: 74-94) attributable to a potentially broad range of health care delivery factors. Limitations included insufficient data to explore how specific health care delivery factors, including structural racism and social determinants, impact differential treatment.

CONCLUSIONS

Our results show the inadequacy of patient health differences as an explanation of the treatment inequity.

IMPACT

Investing in studies and interventions that support equitable health care delivery for Black individuals with prostate cancer will contribute to improved outcomes.

Prostate cancer screening in African American men: a review of the evidence

BACKGROUND

Prostate cancer is the most diagnosed cancer in African American men, yet prostate cancer screening regimens in this group are poorly guided by existing evidence, given underrepresentation of African American men in prostate cancer screening trials. It is critical to optimize prostate cancer screening and early detection in this high-risk group because underdiagnosis may lead to later-stage cancers at diagnosis and higher mortality while overdiagnosis may lead to unnecessary treatment.

METHODS

We performed a review of the literature related to prostate cancer screening and early detection specific to African American men to summarize the existing evidence available to guide health-care practice.

RESULTS

Limited evidence from observational and modeling studies suggests that African American men should be screened for prostate cancer. Consideration should be given to initiating screening of African American men at younger ages (eg, 45-50 years) and at more frequent intervals relative to other racial groups in the United States. Screening intervals can be optimized by using a baseline prostate-specific antigen measurement in midlife. Finally, no evidence has indicated that African American men would benefit from screening beyond 75 years of age; in fact, this group may experience higher rates of overdiagnosis at older ages.

CONCLUSIONS

The evidence base for prostate cancer screening in African American men is limited by the lack of large, randomized studies. Our literature search supported the need for African American men to be screened for prostate cancer, for initiating screening at younger ages (45-50 years), and perhaps screening at more frequent intervals relative to men of other racial groups in the United States.

Racial disparities in prostate cancer mortality: a model-based decomposition of contributing factors

To investigate the relative contributions of natural history and clinical interventions to racial disparities in prostate cancer mortality in the United States, we extended a model that was previously calibrated to Surveillance, Epidemiology, and End Results (SEER) incidence rates for the general population and for Black men. The extended model integrated SEER data on curative treatment frequencies and cancer-specific survival. Starting with the model for all men, we replaced up to 9 components with corresponding components for Black men, projecting age-standardized mortality rates for ages 40-84 years at each step. Based on projections in 2019, the increased frequency of developing disease, more aggressive tumor features, and worse cancer-specific survival in Black men diagnosed at local-regional and distant stages explained 38%, 34%, 22%, and 8% of the modeled disparity in mortality. Our results point to intensified screening and improved care in Black men as priority areas to achieve greater equity.

Inequities in Definitive Treatment for Localized Prostate Cancer Among Those With Clinically Significant Mental Health Disorders

INTRODUCTION

Patients with mental health disorders are at risk for receiving inequitable cancer treatment, likely resulting from various structural, social, and health-related factors. This study aims to assess the relationship between mental health disorders and the use of definitive treatment in a population-based cohort of those with localized, clinically significant prostate cancer.

METHODS

We conducted a cohort study analysis in SEER (Surveillance, Epidemiology, and End Results)-Medicare (2004-2015). History of a mental health disorder was defined as presence of specific ICD (International Classification of Diseases)-9 or ICD-10 diagnostic codes in the 2 years preceding cancer diagnosis. Descriptive statistics were performed using Wilcoxon rank-sum and χ2 testing. Multivariable logistic regression was used to evaluate the relationship between mental health disorders and definitive treatment utilization (defined as surgery or radiation).

RESULTS

Of 101,042 individuals with prostate cancer, 7,945 (7.8%) had a diagnosis of a mental health disorder. They were more likely to be unpartnered, have a lower socioeconomic status, and less likely to receive definitive treatment (61.8% vs 68.2%, P < .001). Definitive treatment rates were >66%, 62.8%, 60.3%, 58.2%, 54.3%, and 48.1% for post-traumatic stress disorder, depressive disorder, bipolar disorder, anxiety disorder, substance abuse disorder, and schizophrenia, respectively. After adjusting for age, race and ethnicity, marital status and socioeconomic status, history of a mental health disorder was associated with decreased odds of receiving definitive treatment (OR 0.74, 95% CI 0.66-0.83).

CONCLUSIONS

Individuals with mental health disorders and prostate cancer represent a vulnerable population; careful attention to clinical and social needs is required to support appropriate use of beneficial treatments.

Racial and sex differences in tumor genomics in urothelial carcinoma

PURPOSE

Differences in bladder cancer outcomes have been demonstrated by sex and race/ethnicity, with studies showing a higher burden of adverse outcomes among women and racially minoritized populations. Despite these epidemiologic differences, populations with disproportionally adverse outcomes are often underrepresented in genomic cohorts. This exclusion impacts the accuracy and generalizability of genomic studies in bladder cancer and has the potential to widen disparities by sex and/or race/ethnicity.

BASIC PROCEDURES

We analyzed pooled somatic mutational data from publicly available cohorts in the cBioPortal open access platform.

FINDINGS

A total of 796 unique patients were identified. Average age for the cohort was 67 years (range: 25-98 years), 188 (24%) were female, and the majority were White (n = 423, 85% among those who report race). Median total mutation count was 91 (IQR: 20, 202) per patient. We used multivariable logistic regression to independently evaluate the association between race/sex and mutation status in each of 122 genes of interest, identified from TCGA, adjusting for age and bladder cancer invasive status. In adjusted analyses, male sex was associated with increased risk of mutation in ARID1A, CHD6, and NCOR1 compared with female sex. White race was associated with increased risk of mutation in ARID1A, EP300, PIK3CA, and TP53 and decreased risk of mutation in HRAS compared with non-White race.

CONCLUSIONS

These differences highlight the importance of enriching cohorts for female and non-White patients in genomic studies and clinical trials, especially as we test the use of molecular biomarkers to personalize care for patients with bladder cancer.

Determining clinical perspectives and strategies for improving enrollment of minoritized communities in prostate cancer clinical trials

BACKGROUND

Black men and other minoritized populations have represented 4-5% or less of participants in most practice-informing clinical trials. This study sought to assess the knowledge, attitudes, and practices of clinicians around equity and inclusion in prostate cancer clinical trial initiatives in the United States.

METHODS

An anonymous, web-based questionnaire was administered via REDCap (Research Electronic Data Capture) with questions focused on inclusivity of minoritized populations with respect to race and ethnicity in prostate cancer clinical trials research. The survey link was distributed across the United States via several professional organizations, prostate cancer groups, and social media. Responses were analyzed both quantitatively (descriptive statistics) and qualitatively (thematic analysis).

RESULTS

Overall, 131 respondents completed the survey (70% self-identified as White, 17% as Asian, and 6% as Black). Most respondents practiced in an urban setting (89%). Of those who engaged in outreach with minoritized communities during the trial design process, 69% observed improved enrollment of minoritized populations. However, 18% of respondents noted that outreach alone does not overcome existing structural barriers to participation in clinical trials. Thematic analysis identified four key areas to address for improving equity: structural, health system, trial-/study-specific, and relationship-/engagement-related factors.

CONCLUSION

Study participants demonstrated a knowledge of the importance of improving equity in prostate cancer clinical trials research. Designing trials that reduce issues associated with access and improving community outreach were emphasized as key focus areas for reducing health disparities in prostate cancer clinical trials research.

Proton Radiation Therapy for Stage IIA/IIB Testicular Seminoma

PURPOSE/OBJECTIVE(S)

Testicular seminoma affects young men and is associated with very favorable prognosis. The evolution in treatment paradigm has focused on minimizing acute and especially late toxicities. Following orchiectomy, while surveillance is favored in Stage I patients, radiotherapy (RT) is a standard treatment option for de novo or relapsed stage IIA or select non-bulky stage IIB disease. Despite low doses, standard RT fields to paraaortic and pelvic lymphatics using x-rays exposes a large volume of uninvolved normal tissue/viscera to excess dose. This young patient population is especially vulnerable to risks of late RT toxicities including secondary malignancy. Proton beam therapy (PBT) has dosimetric advantage over x-ray-based RT due to lack of exit dose, and comparative dosimetric/modeling studies show significant sparing of uninvolved abdominal/pelvic organs. However, there is scant reported clinical data at this time for PBT. We review our early institutional outcomes with PBT for testicular seminoma.

MATERIALS/METHODS

Single institution retrospective review from a tertiary care center of patients treated with PBT from 2013-2022 for testicular seminoma. Recurrence free (RFS) and overall survival (OS) were calculated from the completion of PBT. Toxicities were graded (Gr) using CTCAE v5.0.

RESULTS

Four patients underwent PBT, median age 39 (range 36-47). All were Stage I at diagnosis (pT1b n = 3; pT2 n = 1) and were treated for recurrent stage II disease (IIA n = 3; IIB n = 1) at a median of 34 months from orchiectomy (range 3 - 74 months). Nodal extent included 2 with multiple paraaortic nodes, 1 with solitary paraaortic node and 1 with solitary pelvic node. PBT was delivered with pencil-beam scanning, treating paraaortic + ipsilateral pelvic fields (20 Gy in 10 fractions), then sequential boost to involved nodes (10 -16 Gy in 5-8 fractions). Typically, PA or posterior oblique fields were used to minimize dose to out-of-field abdominal/pelvic viscera. Treatment was well tolerated with minimal acute toxicities: fatigue Gr 1 (n = 3), nausea Gr 1 (n = 3). No Gr 2 or higher acute toxicities or significant late toxicities were observed. At median follow up of 30 months (range 3 - 54), no recurrences were observed, and RFS and OS were 100%. Two patients are without evidence of disease > 4 years post-treatment.

CONCLUSION

In this case series, PBT for retroperitoneal and pelvic metastases in Stage IIA/IIB testicular seminoma was associated with oncologic efficacy with minimal toxicity. PBT reduces unnecessary dose to abdominal/pelvic organs compared to x-ray techniques, which is advantageous in young patients who have anticipated long-term survival. This is one of the few series reporting clinical outcomes of PBT in the management of seminoma. Randomized comparisons with x-ray approaches are impractical given the relatively low volume of patients receiving RT in modern seminoma management, so it is essential to report and track longitudinal outcomes across institutions to validate this approach.

Disparities in prostate cancer

Despite substantial advances in early detection/prevention and treatments, and improved outcomes in recent decades, prostate cancer continues to disproportionately affect Black men and is the secondleading cause of cancer death in this subgroup. Black men are substantially more likely to develop prostate cancer and are twice as likely to die from the disease compared with White men. In addition, Black men are younger at diagnosis and face a higher risk of aggressive disease relative to White men. Striking racial disparities endure along the continuum of prostate cancer care, including screening, genomic testing, diagnostic procedures, and treatment modalities. The underlying causes of these inequalities are complex and multifactorial and involve biological factors, structural determinants of equity (i.e., public policy, structural and systemic racism, economic policy), social determinants of health (including income, education, and insurance status, neighborhood/physical environment, community/social context, and geography), and health care factors. The objective of this article is to review the sources of racial disparities in prostate cancer and to propose actionable recommendations to help address these inequities and narrow the racial gap.

Estimating the Number of Men Living with Metastatic Prostate Cancer in the United States

BACKGROUND

Metastatic prostate cancer (MPC) includes metastases detected at diagnosis (de novo) and those occurring after diagnosis with early-stage disease (recurrent). Cancer registries collect data only on de novo MPC, providing a partial picture of the burden of MPC. We use cancer registry data to estimate the number of men living with MPC in the United States including both de novo and recurrent cases.

METHODS

We apply a back-calculation method to estimate MPC incidence and prevalence from U.S. prostate cancer mortality and de novo MPC relative survival for cases diagnosed between 2000 and 2017 in 18 Surveillance, Epidemiology, and End Results registries. We hold overall prostate cancer mortality and MPC survival constant for future prevalence projections.

RESULTS

On January 1, 2018, we estimated 120,400 U.S. men living with MPC (45% de novo, 55% recurrent). The age-adjusted prevalence in 2018 for Black men was over double that of White men (137.1 vs. 62.2 per 100,000 men). By 2030, 192,500 men are expected to be living with MPC, with the increase being driven by population growth projections.

CONCLUSIONS

The number of men living with MPC in the United States exceeds 100,000 and represents a small fraction of the >3 million men living with a prior diagnosis of prostate cancer.

IMPACT

Relatively similar fractions of de novo and recurrent MPC among prevalent cases highlight opportunities for management of localized disease in reducing the MPC burden. Changes in diagnostic technologies could lead to greater growth in MPC cases in the United States than projected. See related commentary by Stopsack et al., p. 585.

Analysis of evolutionary dynamics and clonal architecture in prostate cancer

The extent to which clinical and genomic characteristics associate with prostate cancer clonal architecture, tumor evolution, and therapeutic response remains unclear. Here, we reconstructed the clonal architecture and evolutionary trajectories of 845 prostate cancer tumors with harmonized clinical and molecular data. We observed that tumors from patients who self-reported as Black had more linear and monoclonal architectures, despite these men having higher rates of biochemical recurrence. This finding contrasts with prior observations relating polyclonal architecture to adverse clinical outcomes. Additionally, we utilized a novel approach to mutational signature analysis that leverages clonal architecture to uncover additional cases of homologous recombination and mismatch repair deficiency in primary and metastatic tumors and link the origin of mutational signatures to specific subclones. Broadly, prostate cancer clonal architecture analysis reveals novel biological insights that may be immediately clinically actionable and provide multiple opportunities for subsequent investigation.

Statement of significance

Tumors from patients who self-reported as Black demonstrate linear and monoclonal evolutionary trajectories yet experience higher rates of biochemical recurrence. In addition, analysis of clonal and subclonal mutational signatures identifies additional tumors with potentially actionable alterations such as deficiencies in mismatch repair and homologous recombination.

Racial inequities in the quality of surgical care among Medicare beneficiaries with localized prostate cancer

BACKGROUND

US Black men are twice as likely to die from prostate cancer as men of other races. Lower quality care may contribute to this higher death rate.

METHODS

Sociodemographic and clinical data were obtained for men in Surveillance, Epidemiology, and End Results-Medicare diagnosed with clinically localized prostate cancer (cT1-4N0/xM0/x) and managed primarily by radical prostatectomy (2005-2015). Surgical volume was determined for facility and surgeon. Relationships between race, surgeon and/or facility volume, and characteristics of treating facility with survival (all-cause and cancer-specific) were assessed using multivariable Cox regression and competing risk analysis.

RESULTS

Black men represented 6.7% (n = 2123) of 31,478 cohort. They were younger at diagnosis, had longer time from diagnosis to surgery, lower socioeconomic status, higher prostate-specific antigen (PSA), and higher comorbid status compared with men of other races (p < .001). They were less likely to receive care from a surgeon or facility in the top volume percentile (p < .001); less likely to receive surgical care at a National Cancer Institute-designated cancer center and more likely seen at a minority-serving hospital; and less likely to travel ≥50 miles for surgical care. On multivariable analysis stratified by surgical volume, Black men receiving care from a surgeon or facility with lower volumes demonstrated increased risk of prostate cancer mortality (hazard ratio, 1.61; 95% confidence interval, 1.01-2.69) adjusting for age, clinical stage, PSA, and comorbidity index.

CONCLUSIONS

Black Medicare beneficiaries with prostate cancer more commonly receive care from surgeons and facilities with lower volumes, likely affecting surgical quality and outcomes. Access to high-quality prostate cancer care may reduce racial inequities in disease outcomes, even among insured men.

PLAIN LANGUAGE SUMMARY

Black men are twice as likely to die of prostate cancer than other US men. Lower quality care may contribute to higher rates of prostate cancer death. We used surgical volume to evaluate the relationship between race and quality of care. Black Medicare beneficiaries with prostate cancer more commonly received care from surgeons and facilities with lower volumes, correlating with a higher risk of prostate cancer death and indicating scarce resources for care. Access to high-quality prostate cancer care eases disparities in disease outcomes. Patient-centered interventions that increase access to high-quality care for Black men with prostate cancer are needed.

Does Clinical Evidence of Heterogeneity Impact Treatment Selection? A Case Study of Abiraterone for Metastatic Prostate Cancer

BACKGROUND

Two pivotal randomized controlled trials (RCTs) demonstrate that abiraterone acetate + prednisone (AAP) combined with androgen deprivation therapy (ADT) significantly extends the survival of men with metastatic hormone-sensitive prostate cancer (mHSPC) compared with ADT alone. Their subgroup analyses indicate that the survival benefit is significant for younger men but not older men. We aimed to assess whether publication of the RCTs was associated with differential real-world AAP utilization by age groups.

METHODS

Using TriNetX electronic medical records data collected from 43 healthcare organizations across the United States, we performed a difference-in-differences event study among men with newly diagnosed mHSPC observed from June 2014 to June 2019. Eligible subjects were identified based on a comprehensive published algorithm. We analyzed the change in utilization rate of AAP before versus after publication of the RCTs among men aged &lt;70 years versus ≥70 years, adjusting for demographic factors and clinical conditions.

RESULTS

Our study included 6,888 men with newly diagnosed mHSPC with 12,738 observations, of whom 46% were aged &lt;70 years. The prepublication trends of AAP utilization were similar between the age groups, whereas publication of the RCTs was associated with a 3.5% higher adjusted uptake rate of AAP among younger men (95% CI, 1.2%-5.8%) relative to older men. This estimate reflects an uptake rate nearly 3 times higher than would have been expected had younger men followed the same utilization trends as older men. The estimates remained consistent throughout the postpublication period.

CONCLUSIONS

Our study suggests that publication of the RCTs was associated with faster uptake of AAP among younger versus older men with newly diagnosed mHSPC, despite the absence of clinical guidance for differential treatment selection. This finding highlights the importance of confirmatory studies among older men, considering the uncertainties of subgroup analyses in RCTs.

Deconstructing, Addressing, and Eliminating Racial and Ethnic Inequities in Prostate Cancer Care

CONTEXT

Men of African ancestry have demonstrated markedly higher rates of prostate cancer mortality than men of other races and ethnicities around the world. In fact, the highest rates of prostate cancer mortality worldwide are found in the Caribbean and Sub-Saharan West Africa, and among men of African descent in the USA. Addressing this inequity in prostate cancer care and outcomes requires a focused research approach that creates durable solutions to address the structural, social, environmental, and health factors that create racial disparities in care and outcomes.

OBJECTIVE

To introduce a conceptual model for evaluating racial inequities in prostate cancer care to facilitate the development of translational research studies and interventions.

EVIDENCE ACQUISITION

A collaborative review of literature relevant to racial inequities in prostate cancer care and outcomes was performed. Existing literature was used to highlight various components of the conceptual model to inform future research and interventions toward equitable care and outcomes.

EVIDENCE SYNTHESIS

Racial inequities in prostate cancer outcomes are driven by a series of structural and social determinants of health that impact exposures, mediators, and outcomes. Social determinants of equity, such as laws/policies, economic systems, and structural racism, affect the inequitable access to environmental and neighborhood exposures, in addition to health care access. Although the incidence disparity remains problematic, various studies have demonstrated parity in outcomes when social and health factors, such as access to equitable care, are normalized. Few studies have tested interventions to reduce inequities in prostate cancer among Black men.

CONCLUSIONS

Worldwide, men of African ancestry demonstrate worse outcomes in prostate cancer, a phenomenon driven largely by social factors that inform biologic, environmental, and health care risks. A conceptual model was presented that organizes the many factors that influence prostate cancer incidence and mortality. Within that framework, we must understand the current state of inequities in clinical prostate cancer practice, the optimal state of what equitable practice would be, and how achieving equity in prostate cancer care balances costs, benefits, and harms. More robust characterization of the sources of prostate cancer inequities should inform testing of ambitious and innovative interventions as we work toward equity in care and outcomes.

PATIENT SUMMARY

Men of African ancestry demonstrate the highest rates of prostate cancer mortality, which may be reduced through social interventions. We present a framework for formalizing the identification of the drivers of prostate cancer inequities to facilitate the development of interventions and trials to eradicate them.

Naloxegol versus Alvimopan for Enhancing Postoperative Recovery following Radical Cystectomy for Bladder Cancer

INTRODUCTION

µ-Opioid-receptor antagonists are a standard component of enhanced recovery after surgery (ERAS) pathways following radical cystectomy (RC) as they reduce ileus and shorten length of stay (LOS). Prior studies have used alvimopan; however, naloxegol is a less expensive medication in the same class. We compared differences in postoperative outcomes between patients receiving alvimopan or naloxegol following RC.

METHODS

We retrospectively reviewed all patients undergoing RC over 20 months at an academic center during which standard practice transitioned from using alvimopan to naloxegol, while maintaining all other components of our ERAS pathway. We utilized bivariate comparisons as well as negative binomial and logistic regression to compare return of bowel function, rates of ileus and LOS following RC.

RESULTS

Of 117 eligible patients, 59 (50%) received alvimopan and 58 (50%) received naloxegol. There were no differences in baseline clinical, demographic or perioperative factors. Median postoperative LOS was 6 days in each group (p=0.3). Time to flatus (2 versus 2 days, p=0.2) and ileus (14% versus 17%, p=0.6) were similar between the alvimopan and naloxegol groups, respectively. In multivariable models controlling for patient and surgical factors, µ-opioid antagonist agent was associated with neither LOS nor ileus. Cost difference was -$344.20/day, equivalent to a $2,065.20 savings over a 6-day hospital stay with naloxegol.

CONCLUSIONS

In patients undergoing RC managed with a standard ERAS pathway, there were no differences in postoperative recovery based on the use of alvimopan versus naloxegol. Substitution of naloxegol for alvimopan may allow for significant cost savings without compromising outcomes.

Harm-to-Benefit of Three Decades of Prostate Cancer Screening in Black Men

BACKGROUND

Prostate-specific antigen screening has profoundly affected the epidemiology of prostate cancer in the United States. Persistent racial disparities in outcomes for Black men warrant re-examination of the harms of screening relative to its cancer-specific mortality benefits in this population.

METHODS

We estimated overdiagnoses and overtreatment of prostate cancer for men of all races and for Black men 50 to 84 years of age until 2016, the most recent year with treatment data available, using excess incidence relative to 1986 based on the Surveillance, Epidemiology, and End Results registry and U.S. Census data as well as an established microsimulation model of prostate cancer natural history. Combining estimates with plausible mortality benefit, we calculated numbers needed to diagnose (NND) and treat (NNT) to prevent one prostate cancer death.

RESULTS

For men of all races, we estimated 1.5 to 1.9 million (range between estimation approaches) overdiagnosed and 0.9 to 1.5 million overtreated prostate cancers by 2016. Assuming that half of the 270,000 prostate cancer deaths avoided by 2016 were attributable to screening, the NND and the NNT would be 11 to 14 and 7 to 11 for men of all races and 8 to 12 and 5 to 9 for Black men, respectively. Alternative estimates incorporating a lag between incidence and mortality resulted in a NND and a NNT for Black men that reached well into the low single digits.

CONCLUSIONS

Complementary approaches to quantifying overdiagnosis indicate a harm-benefit tradeoff of prostate-specific antigen screening that is more favorable for Black men than for men of all races considered together. Our findings highlight the need to account for the increased value of screening in Black men in clinical guidelines. (Funded by the Patient-Centered Outcomes Research Institute, the National Cancer Institute, the Bristol Myers Squibb Foundation, and the Damon Runyon Cancer Research Foundation.).

Aggressive Prostate Cancer at Presentation Following Solid Organ Transplantation

Solid organ transplant (SOT) candidates and recipients are often subject to intense screening regimens that can potentially delay transplantation and cause unnecessary harm. Although initial studies suggested that SOT recipients had elevated risk of prostate cancer (PCa), contemporary studies have shown that transplant recipients with low- or intermediate-risk PCa have similar outcomes to their counterparts without a transplant. However, there are limited data on the relationship between prior transplant exposure and the risk of clinically significant aggressive PCa at presentation. To provide additional insight, we queried the Surveillance, Epidemiology and End Results-Medicare database to establish a cohort of prostate-specific antigen (PSA)-screened transplant patients who then went on to develop PCa. Procedure and diagnosis codes were then used to identify patients with a history of SOT. Aggressive PCa phenotype was defined as death from PCa or de novo metastasis, regional lymph node metastasis, PSA >20 ng/l, or Gleason score 8–10 at presentation. On univariable and multivariable (adjusted for age and race) analyses, transplant patients (n = 292) were not at significantly higher risk of an aggressive prostate cancer phenotype with odds ratios of 0.95 (95% confidence interval 0.72–1.25) and 1.18, (95% confidence interval 0.90–1.57), respectively. The results suggest that transplant recipients can have similar screening protocols to those for the general population.

Patient summary

Using database results for transplant recipients, we investigated their risk of developing aggressive prostate cancer after transplantation. We found that having a transplant did not increase the risk of aggressive prostate cancer. This work suggests that transplant recipients are unlikely to benefit from more rigorous screening protocols than those for the general population.

Changes in body composition during neoadjuvant platinum-based chemotherapy associations prior to radical cystectomy: Implications for chemotherapy-associated adverse events and oncologic outcomes

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Background: Low skeletal muscle index (SMI) is associated with an increased risk of mortality in muscle-invasive bladder cancer (MIBC) and chemotherapy-related adverse events (AE) across numerous other malignancies. Small case series suggest neoadjuvant chemotherapy (NAC) is associated with a significant decline in SMI in patients with MIBC. However, limited data exists regarding changes in fat mass during NAC. Herein, we examine changes in SMI, visceral fat index (VFI), and subcutaneous fat index (SFI) in patients receiving NAC for MIBC before radical cystectomy (RC). We describe associations between body composition changes and NAC-associated AE and all-cause mortality (ACM) in patients with MIBC. Methods: Retrospective review of patients with MIBC (≥pT2 N0/x/1 M0) who received NAC (2006-2019). Patients with digitized abdominal computed tomography scans (CT) within 75 days prior (T1) and 75 days following completion (T2) of NAC were included. We segmented and calculated the indices (cm2/m2) for SMI, VFI, and SFI at the third lumbar vertebra level at T1 and T2 using validated methodology. Associations with AE during NAC and ACM were evaluated with multivariate logistic regression and Cox proportional hazards models. Results: Included 170 patients, median age 63 years receiving a median of 4 (IQR 3-5) cycles of Gemcitabine/Cisplatin (52%), MVAC (28%), or other NAC (20%). Absolute and relative changes in SMI, VFI, and SFI over a median of 112 days (IQR 94-146) between measurements are presented in the Table. 117 (69%) patients experienced grade ≥3 chemotherapy-related AE. No associations between baseline body composition or change in body composition during NAC with chemotherapy-related AE. T1 SMI (HR: 0.98; 0.97-0.99, p = 0.008), as well as T2 SMI (HR: 0.98; 0.96-0.99, p = 0.003), T2 VFI (HR: 0.99; 0.99-1.0, p = 0.05) and T2 SFI (HR: 0.99; 0.98-1.0, P = 0.03) were associated with ACM after adjusting for age, clinical T and N stage, and performance status. Conclusions: Patients undergoing NAC prior to RC experienced a 6.4% decrease in SMI and a 5.2% decrease in VFI during an average of 112 days. Chemotherapy-related AE were not associated with a change in body composition. Baseline SMI and T2 SMI, SFI, and VFI were associated with ACM on multivariable analysis. Future work is needed to understand the mechanisms underpinning such changes and the extent to which potentially detrimental changes in body composition may be mitigated before surgery.[Table: see text]

Blood and urine biomarkers in prostate cancer: Are we ready for reflex testing in men with an elevated prostate-specific antigen?

Objective

There is no consensus on the role of biomarkers in determining the utility of prostate biopsy in men with elevated prostate-specific antigen (PSA). There are numerous biomarkers such as prostate health index, 4Kscore, prostate cancer antigen 3, ExoDX, SelectMDx, and Mi-Prostate Score that may be useful in this decision-making process. However, it is unclear whether any of these tests are accurate and cost-effective enough to warrant being a widespread reflex test following an elevated PSA. Our goal was to report on the clinical utility of these blood and urine biomarkers in prostate cancer screening.

Methods

We performed a systematic review of studies published between January 2000 and October 2020 to report the available parameters and cost-effectiveness of the aforementioned diagnostic tests. We focus on the negative predictive value, the area under the curve, and the decision curve analysis in comparing reflexive tests due to their relevance in evaluating diagnostic screening tests.

Results

Overall, the biomarkers are roughly equivalent in predictive accuracy. Each test has additional clinical utility to the current diagnostic standard of care, but the added benefit is not substantial to justify using the test reflexively after an elevated PSA.

Conclusions

Our findings suggest these biomarkers should not be used in binary fashion and should be understood in the context of pre-existing risk predictors, patient's ethnicity, cost of the test, patient life-expectancy, and patient goals. There are more recent diagnostic tools such as multi-parametric magnetic resonance imaging, polygenic single-nucleotide panels, IsoPSA, and miR Sentinel tests that are promising in the realm of prostate cancer screening and need to be investigated further to be considered a consensus reflexive test in the setting of prostate cancer screening.

The Impact of Intensifying Prostate Cancer Screening in Black Men: A Model-Based Analysis

BACKGROUND

Black men in the United States have markedly higher rates of prostate cancer than the general population. National guidelines for prostate-specific antigen (PSA) screening do not provide clear guidance for this high-risk population. The purpose of this study is to estimate the benefit and harm of intensified PSA screening in Black men.

METHODS

Two microsimulation models of prostate cancer calibrated to incidence from the Surveillance, Epidemiology, and End Results program among Black men project the impact of different screening strategies (varying screening intervals, starting and stopping ages, and biopsy utilization following an abnormal PSA) on disease-specific mortality and overdiagnosis. Each strategy induces a mean lead time (MLT) for detected cases. A longer MLT reduces mortality according to estimates combining the US and European prostate cancer screening trials but increases overdiagnosis.

RESULTS

Under historical population screening, Black men had similar MLT to men of all races, and similar mortality reduction (range between models = 21-24% vs. 20-24%) but a higher frequency of overdiagnosis (75-86 vs. 58-60 per 1000 men). Screening Black men aged 40-84 years annually would increase both mortality reduction (29-31%) and overdiagnosis (112-129 per 1000). Restricting screening to age 45-69 years would still achieve substantial mortality reduction (26-29%) with lower overdiagnosis (51-61 per 1000). Increasing biopsy utilization to 100% of abnormal tests would further reduce mortality but substantially increase overdiagnosis.

CONCLUSIONS

Annual screening in Black men is expected to reduce mortality more than that estimated under historical screening. Limiting screening to men below 70 years is expected to help to reduce overdiagnosis.

Underutilization of Surgical Standard of Care for Insured Men with Invasive Penile Cancer

PURPOSE

Prior studies of mixed insurance populations have demonstrated poor adherence to surgical standard of care (SOC) for penile cancer. We used data from the Surveillance, Epidemiology and End Results (SEER) cancer registry linked to Medicare to calculate SOC adherence to surgical treatment of penile cancer in insured men over the age of 65, focusing on potential social and racial disparities.

METHODS

This is an observational analysis of patients with T2-4 penile cancer of any histologic subtype without metastasis in the SEER-Medicare database (2004-2015). SOC was defined as penectomy (partial or radical) with bilateral inguinal lymph node dissection (ILND) based on the National Comprehensive Cancer Network guidelines. We calculated proportions of those receiving SOC and constructed multivariate models to identify factors associated with receiving SOC.

RESULTS

A total of 447 men were included. Of these men, 22.1% (99/447) received SOC while 18.8% (84/447) received no treatment at all. Only 23.3% (104/447) had ILND while 80.9% (362/447) underwent total or partial penectomy. Race and socioeconomic status (SES) were not associated with decreased SOC. Increasing age (OR 0.93, 95%CI:0.89-0.96), Charlson Comorbidity Index score ≥ 2 (OR 0.53, 95%CI:0.29-0.97), and T3-T4 disease (OR 0.34, 95%CI:0.18-0.65) were associated with not receiving SOC on adjusted analysis.

CONCLUSIONS

Rates of SOC are low among insured men 65 years of age or older with invasive penile cancer, regardless of race or SES. This finding is largely driven by low rates of ILND. Strategies are needed to overcome barriers to SOC treatment for men with invasive penile cancer.

Oncologic outcomes among Black and White men with grade group 4 or 5 (Gleason score 8-10) prostate cancer treated primarily by radical prostatectomy

BACKGROUND

The aim of this study was to describe pathologic and short-term oncologic outcomes among Black and White men with grade group 4 or 5 prostate cancer managed primarily by radical prostatectomy.

METHODS

This was a multi-institutional, observational study (2005-2015) evaluating radical prostatectomy outcomes by self-identified race. Descriptive analysis was performed via nonparametric statistical testing to compare baseline clinicopathologic data. Univariable and multivariable time-to-event analyses were performed to assess biochemical recurrence (BCR), metastasis, cancer-specific mortality (CSM), and overall survival between Black and White men.

RESULTS

In total, 1662 men were identified with grade group 4 or 5 prostate cancer initially managed by radical prostatectomy. Black men represented 11.3% of the cohort (n = 188). Black men were younger, demonstrated a longer time from diagnosis to surgery, and were at a lower clinical stage (all P < .05). Black men had lower rates of pT3/4 disease (49.5% vs 63.5%; P < .05) but higher rates of positive surgical margins (31.6% vs 26.5%; P = .14) on pathologic evaluation. There was no difference in BCR, CSM, or overall survival over a median follow-up of 40.7 months. Black men had a lower 5-year cumulative incidence of metastasis-free survival (93.6%; 95% confidence interval [CI], 86.5%-97.0%) in comparison with White men (85.8%; 95% CI, 83.1%-88.0%), which did not persist in an age-adjusted analysis.

CONCLUSIONS

Black and White men with high-grade prostate cancer at diagnosis demonstrated similar oncologic outcomes when they were managed by primary radical prostatectomy. Our findings suggest that racial disparities in prostate cancer mortality are not related to differences in the efficacy of extirpative therapy.

Abstract PO-211: Racial disparities in the quality of surgical care among Medicare beneficiaries with prostate cancer

Background: Black men in the US demonstrate a two-fold increase in prostate cancer mortality compared to men of other races/ethnicities. The aim of this analysis was to understand how access to high quality care—estimated using surgical volume— impacts disparities in prostate cancer mortality between Black and White men with localized prostate cancer. Methods: This is an analysis of a SEER-Medicare cohort of men diagnosed with localized prostate cancer (cT1-4N0M0) managed primarily by radical prostatectomy from 2005-2015. This analysis was restricted to Black and White men due to low representative numbers of men of other races/ethnicities.

Social, demographic, and clinical data were obtained. Both facility and provider data were obtained using administrative data in Medicare. Surgical volume for both providers and facilities were stratified into low, medium, and high. Simple descriptive analyses were performed. Multivariable Cox regression analyses was used to assess the relationship between race, surgical volume, and various clinical and social variables. Results: Black men represented 2,070 (7.1%) of the 29,071 men in this cohort. Black men in the cohort had a higher proportion of prostate specific antigen (PSA) greater than 20 ng/mL (7.0% vs 3.6%) and a higher proportion of men with cT1 disease at diagnosis (64.6% vs 56.1%) when compared to White men. Black men were also less likely to be married/partnered (63.5% vs. 79.9%), more likely to reside in an impoverished zip code (43.9% vs. 11.1%), and more likely to have significant comorbidities (7.2% vs. 2.9%). Black men in this cohort were most likely to be treated in the Southern US (42.8% of cases). Black men were more likely to be treated at a minority serving hospital/facility (24.6% vs. 3.1%, p &lt; 0.001), more likely to be treated at a very large hospital/health system (p &lt; 0.001), and less likely to be treated by a high-volume surgeon or facility (7.7% vs. 19.9%, p &lt; 0.001) compared to White men. On multivariable analysis adjusted for race, hospital type, NCI comorbidity index, clinical stage, and prostatectomy volume; black men demonstrated an increased risk of prostate cancer mortality (hazard ratio 1.27, 95% CI 0.94, 1.72) compared to White men. On stratified analysis, there were no racial disparities in cancer-specific mortality among men treated by a high-volume provider/facility. In contrast, Black men treated by a low/medium volume provider/facility had a higher likelihood of prostate cancer related death following surgery (hazard ratio 1.41, 95% CI 1.02, 1.95, p = 0.04). Conclusions: Black Medicare beneficiaries with prostate cancer demonstrate unique patterns of surgical care utilization, with differences noted in the types and surgical volumes—and likely surgical quality—of their health facilities and providers. Our findings suggest that access to high-quality prostate cancer care is an important mediator of racial disparities in prostate cancer, even among men with access to health insurance.

Citation Format: Yaw A. Nyame, Sarah K. Holt, Ruth Etzioni, John L. Gore. Racial disparities in the quality of surgical care among Medicare beneficiaries with prostate cancer [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-211.

Prostate-Specific Antigen Screening and Recent Increases in Advanced Prostate Cancer

Recent studies show decreasing prostate-specific antigen utilization and increasing incidence of metastatic prostate cancer in the United States after national recommendations against screening in 2012. Yet, whether the increasing incidence of metastatic prostate cancer is consistent in magnitude with the expected impact of decreased screening is unknown. We compared observed incidence of metastatic prostate cancer from the Surveillance, Epidemiology, and End Results program and published effects of continued historical screening and discontinued screening starting in 2013 projected by 2 models of disease natural history, screening, and diagnosis. The observed rate of new metastatic prostate cancer cases in 2017 was 44%-60% of the projected increase under discontinued screening relative to continued screening. Thus, the observed increase in incident metastatic prostate cancer is consistent with the expected impact of reduced screening. Although this comparison does not establish a causal relationship, it highlights the plausible role of decreased screening in the observed trend.

Response to Neoadjuvant Chemotherapy and Survival in Micropapillary Urothelial Carcinoma: Data From a Tertiary Referral Center and the Surveillance, Epidemiology, and End Results (SEER) Program

BACKGROUND

Micropapillary urothelial carcinoma (MPC) is a rare urothelial carcinoma variant with conflicting data guiding clinical practice. In this study, we explored oncologic outcomes in relation to neoadjuvant chemotherapy (NAC) in a retrospective cohort of patients with MPC, alongside data from Surveillance, Epidemiology, and End Results (SEER)-Medicare.

PATIENTS AND METHODS

We retrospectively identified patients with MPC or conventional urothelial carcinoma (CUC) without any variant histology undergoing radical cystectomy (RC) in our institution (2003-2018). SEER-Medicare was also queried to identify patients diagnosed with MPC (2004-2015). Clinicopathologic data and treatment modalities were extracted. Overall survival (OS) was estimated with the Kaplan-Meier method. Mann-Whitney-Wilcoxon and chi-square tests were used for comparative analysis and Cox regression for identifying clinical covariates associated with OS.

RESULTS

Our institutional database yielded 46 patients with MPC and 457 with CUC. In SEER-Medicare, 183 patients with MPC were identified, and 63 (34%) underwent RC. In the institutional cohort, patients with MPC had significantly higher incidence of cN+ (17% vs. 8%), pN+ stage (30% vs. 17%), carcinoma-in-situ (43% vs. 25%), and lymphovascular invasion (30% vs. 16%) at RC versus those with CUC (all P < .05). Pathologic complete response (ypT0N0) to NAC was 33% for MPC and 35% for CUC (P = .899). Median OS was lower for institutional MPC versus CUC in univariate analysis (43.6 vs. 105.3 months, P = .006); however, MPC was not independently associated with OS in the multivariate model. Median OS was 25 months in the SEER MPC cohort for patients undergoing RC, while NAC was not associated with improved OS in that group.

CONCLUSION

Pathologic response to NAC was not significantly different between MPC and CUC, while MPC histology was not an independent predictor of OS. Further studies are needed to better understand biological mechanisms behind its aggressive features as well as the role of NAC in this histology variant.

DNA methylation and cis-regulation of gene expression by prostate cancer risk SNPs

Genome-wide association studies have identified more than 100 SNPs that increase the risk of prostate cancer (PrCa). We identify and compare expression quantitative trait loci (eQTLs) and CpG methylation quantitative trait loci (meQTLs) among 147 established PrCa risk SNPs in primary prostate tumors (n = 355 from a Seattle-based study and n = 495 from The Cancer Genome Atlas, TCGA) and tumor-adjacent, histologically benign samples (n = 471 from a Mayo Clinic study). The role of DNA methylation in eQTL regulation of gene expression was investigated by data triangulation using several causal inference approaches, including a proposed adaptation of the Causal Inference Test (CIT) for causal direction. Comparing eQTLs between tumors and benign samples, we show that 98 of the 147 risk SNPs were identified as eQTLs in the tumor-adjacent benign samples, and almost all 34 eQTL identified in tumor sets were also eQTLs in the benign samples. Three lines of results support the causal role of DNA methylation. First, nearly 100 of the 147 risk SNPs were identified as meQTLs in one tumor set, and almost all eQTLs in tumors were meQTLs. Second, the loss of eQTLs in tumors relative to benign samples was associated with altered DNA methylation. Third, among risk SNPs identified as both eQTLs and meQTLs, mediation analyses suggest that over two-thirds have evidence of a causal role for DNA methylation, mostly mediating genetic influence on gene expression. In summary, we provide a comprehensive catalog of eQTLs, meQTLs and putative cancer genes for known PrCa risk SNPs. We observe that a substantial portion of germline eQTL regulatory mechanisms are maintained in the tumor development, despite somatic alterations in tumor genome. Finally, our mediation analyses illuminate the likely intermediary role of CpG methylation in eQTL regulation of gene expression.

Racial and sex differences in somatic mutations in bladder cancer patients: An analysis of the cBioPortal for Cancer Genomics

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Background: Disparities in bladder cancer outcomes exist by race/ethnicity and sex. However, limited data exists on differences in tumor biology by race/ethnicity and sex. Methods: This is a retrospective analysis of non-synonymous mutational data from the cBioPortal open access platform. A total of eight unique cohorts were identified. The cohort was divided into groups by sex and race. Somatic mutations were selected from those with frequency > 7% from TCGA and DNA damage repair (DDR) genes. Univariable analysis was performed using Student’s t-test and Fischer’s exact test. For those genes with significant differences, multivariate Cox regression analysis was performed, including a test for interaction for genes significantly associated with race or gender. Results: A total of 917 unique patients were identified from cBioPortal for this analysis. Median age for the cohort was 68 years (range: 25-98) and 227 (25%) were identified as female. The cohort was majority white (85%). TP53 (54% vs. 31%, p < 0.001), ARID1A (29% vs. 7%, p < 0.001), ERBB3 (12% vs. 3%, p = 0.01) and CDKN1A (8% vs 18%, p = 0.02) were differentially mutated in white tumors compared to non-white tumors. ERBB2 was more common among male (13%) compared to female (6%) patients in the cohort (p < 0.01). There were no differences in DDR genes by race/ethnicity and sex. The median age for those with ERCC2 (70.4 vs. 66.8 years) and RAD51 (76.3 vs. 67.0 years) mutations was higher compared to those without the mutations, respectively. On multivariable analysis, ERCC2 (HR 0.45, 95% CI 0.25, 080), SPTAN1 (HR 0.50, 95% CI 0.29, 0.84), and EP300 (HR 0.60, 95% CI 0.39, 0.92) were associated with survival. There was a significant interaction between white race and CDKN1A in the survival analysis, with non-white patients with CKDN1A mutations having increased hazard for mortality (HR 3.1, 95% CI 1.14, 8.42). Conclusions: Somatic mutational differences existed by both race and gender in a large cohort of patients with bladder cancer. These findings are limited by poor representation of non-white patients and retrospective design; advocating for representative patient cohorts to assess tumor biology in bladder cancer disparities research.

What is the Impact of Racial Disparities on Diagnosis and Receipt of Appropriate Mental Health Care Among Urology Patients?

Patients with chronic disease and mental illness are at higher risk of depression and suicide. Many who have been diagnosed with genitourinary cancers are at higher risk of suicide, even among those who have sought out mental health services. Under-represented populations (African-American, Hispanic, elderly, disabled) suffer disproportionately from a lack of mental health services. However, not much is reported on the interplay of mental health and genitourinary cancer in these populations. This review aims to identify the relevant literature and describe a path forward to address and alleviate this disparity. PATIENT SUMMARY: Patients with chronic disease and mental illness are at higher risk of depression and suicide. Little is known about the complex interplay between race and mental health in patients with urologic cancers and more research is needed.

Increasing use of neoadjuvant chemotherapy (NAC) in muscle-invasive bladder cancer (MIBC): Prognostic impact of non-standard of care (SOC) regimens

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Background: Cisplatin-based NAC can prolong overall survival (OS) in patients (pts) with MIBC. Utilization of NAC has increased to about 20% of pts with MIBC over the last decade. We evaluated NAC utilization with and without SOC cisplatin-based combination regimens and oncologic outcomes using registry data. Methods: This is a population-based analysis of linked SEER-Medicare data (2004-2011). We identified 4534 pts with MIBC (cT2-4N0-1) undergoing radical cystectomy (RC). Based on pharmacy records data, pts were stratified into 3 groups: SOC, non-SOC, and immediate cystectomy (IC). We used descriptive statistics to compare groups, and multivariate logistic regression to define factors associated with receiving SOC NAC. Competing risk bladder cancer-specific mortality (BCSM) incidence curves were generated and KM analysis was used to assess OS from time of RC. The impact of NAC on OS was evaluated with Cox regression analysis. Results: 694 (15.3%) pts received NAC, increasing from 11% in 2004 to 24.8% in 2011, with 345 (50%) receiving non-SOC, e.g. gemcitabine/carboplatin (49.3%), gemcitabine alone (21.2%), carboplatin alone (14.8%), cisplatin alone (8.4%), and methotrexate/vinblastine/ adriamycin/carboplatin (0.8%). On logistic regression, increasing age (OR 0.91, 95%CI 0.88 – 0.94, p < 0.0001), Hispanic/Latin ethnicity (OR 0.49, 95%CI 0.22 – 1.10, p = 0.08), and ≥moderate renal dysfunction (OR 0.20, 95%CI 0.08 – 0.51, p < 0.001) were associated with lower odds of SOC NAC. Non-SOC NAC was associated with higher BCSM (competing risk) and lower OS (KM) vs. IC and SOC NAC. On multivariable analysis, non-SOC NAC was associated with higher risk of BCSM (HR 1.35, 95%CI 1.06 – 1.72, p = 0.01) and lower OS (HR 1.38, 95%CI 1.11 – 1.70, p = 0.003) vs. SOC NAC. Conclusions: About 50% of pts receiving NAC were not treated with SOC regimens. Non-SOC NAC was associated with higher bladder cancer death risk. This stresses the role of SOC NAC ideally in a multidisciplinary expert setting, as well as the need for timely RC and neoadjuvant clinical trials, including cisplatin-ineligible pts.

Older Age at Diagnosis and Initial Disease Volume Predict Grade Reclassification Risk on Confirmatory Biopsy in Patients Considered for Active Surveillance

OBJECTIVE

To identify which active surveillance candidates benefit most from confirmatory biopsies to exclude grade underclassification.

MATERIALS AND METHODS

This observational study includes 556 men diagnosed between 2002 and 2015 with Gleason 3 + 3 (GG1) disease on initial diagnostic biopsy, of whom 406 received a confirmatory biopsy within 12 months for active surveillance. Multivariable logistic regression analysis was performed to determine clinicopathologic features associated with Gleason 7 or higher (GG2+) on a confirmatory biopsy. Regression tree analysis was employed to stratify patients into select risk groups.

RESULTS

Eighty-five of 406 patients (20.9%) with initially GG1 disease were reclassified to GG2+ on a confirmatory biopsy. On multivariable analysis, increasing age (per year odds ratio 1.07; 95% confidence interval 1.02-1.12; P <.01) and more positive cores at diagnosis (per core, odds ratio 1.37, 95% confidence interval 1.09-1.72; P <.01) were significantly associated with reclassification, independent of prostate volume, clinical stage, initial PSA, or confirmatory biopsy type (including magnetic resonance imaging-targeted approaches or transrectal saturation random sampling). Recursive partitioning demonstrated that age over 73 and 5 or more positive cores were factors associated with the greatest reclassification risk.

CONCLUSION

In our cohort, both advancing age and additional positive cores were associated with increased odds of reclassification to GG2+ on confirmatory biopsy. In men over age 73 or with 5 or more positive cores, a repeat biopsy within 12 months may be particularly beneficial to minimize tumor grade underclassification.