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. 2020 Mar 2;3(3):e201255.
doi: 10.1001/jamanetworkopen.2020.1255.

Association of Sociodemographic and Health-Related Factors With Receipt of Nondefinitive Therapy Among Younger Men With High-Risk Prostate Cancer

Alexander F Bagley  1 , Mitchell S Anscher  1 , Seungtaek Choi  1 , Steven J Frank  1 , Karen E Hoffman  1 , Deborah A Kuban  1 , Sean E McGuire  1 , Quynh-Nhu Nguyen  1 , Brian Chapin  2 , Ana Aparicio  3 , Todd A Pezzi  1 , Grace L Smith  1   4 , Benjamin D Smith  1   4 , Kenneth Hess  5 , Chad Tang  1
Affiliations

Association of Sociodemographic and Health-Related Factors With Receipt of Nondefinitive Therapy Among Younger Men With High-Risk Prostate Cancer

Alexander F Bagley et al. JAMA Netw Open. .

Erratum in

  • Error in Table 3.
    [No authors listed] [No authors listed] JAMA Netw Open. 2020 Apr 1;3(4):e205306. doi: 10.1001/jamanetworkopen.2020.5306. JAMA Netw Open. 2020. PMID: 32282042 Free PMC article. No abstract available.

Abstract

Importance: Multiple randomized clinical trials have shown that definitive therapy improves overall survival among patients with high-risk prostate cancer. However, many patients do not receive definitive therapy because of sociodemographic and health-related factors.

Objective: To identify factors associated with receipt of nondefinitive therapy (NDT) among patients aged 70 years and younger with high-risk prostate cancer.

Design, setting, and participants: This cohort study identified 72 036 patients aged 70 years and younger with high-risk prostate cancer and Charlson Comorbidity Index scores of 2 or less who were entered in the National Cancer Database between January 2004 and December 2014. Data analysis was conducted from November 2018 to December 2019.

Exposure: Receipt of NDT as an initial treatment approach.

Main outcomes and measures: Survival rates were compared based on receipt of definitive therapy or NDT, and sociodemographic and health-related factors were associated with the type of therapy received. Residual life expectancy was estimated from the National Center for Health Statistics to calculate person-years of life lost.

Results: A total of 72 036 men with a median (range) age of 63 (30-70) years, Charlson Comorbidity Index scores of 2 or less, and high-risk prostate cancer without regional lymph node or distant metastatic disease were analyzed. Among eligible patients, 5252 (7.3%) received NDT as an initial therapeutic strategy. On univariate and multivariate analyses, NDT was associated with worse overall survival (univariate analysis hazard ratio, 2.54; 95% CI, 2.40-2.69; P < .001; multivariate analysis hazard ratio, 2.40; 95% CI, 2.26-2.56; P < .001). Compared with patients with private insurance or managed care, those with no insurance, Medicaid, or Medicare were more likely to receive systemic therapy only (no insurance: odds ratio [OR], 3.34; 95% CI, 2.81-3.98; P < .001; Medicaid: OR, 2.92; 95% CI, 2.48-3.43; P < .001; Medicare: OR, 1.36; 95% CI, 1.20-1.53; P < .001) or no treatment (no insurance: OR, 2.63; 95% CI, 2.24-3.08; P < .001; Medicaid: OR, 1.71; 95% CI, 1.45-2.01; P < .001; Medicare: OR, 1.14; 95% CI, 1.04-1.24; P = .004). Compared with white patients, black patients were more likely to receive systemic therapy only (OR, 1.93; 95% CI, 1.74-2.14; P < .001) or no treatment (OR, 1.46; 95% CI, 1.32-1.61; P < .001), and Hispanic patients were more likely to receive systemic therapy only (OR, 1.36; 95% CI, 1.13-1.64; P = .001) or no treatment (OR, 1.36; 95% CI, 1.14-1.60; P < .001). Between 2004 and 2014, patients without insurance or enrolled in Medicaid had 1.83-fold greater person-years of life lost compared with patients with private insurance (area under the curve, 77 600 vs 42 300 person-years of life lost).

Conclusions and relevance: In this study, receipt of NDT was associated with insurance status and race/ethnicity. While treatment decisions should be individualized for every patient, younger men with high-risk prostate cancer and minimal comorbidities should be encouraged to receive definitive local therapy regardless of other factors. These data suggest that significant barriers to life-extending treatment options for patients with prostate cancer remain.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Frank reported receiving personal fees from Varian Medical Systems and Boston Scientific; receiving grants from Hitachi, Eli Lilly and Co, and ELEKTA; receiving personal fees and grants from C4 Imaging; and holding a patent with C4 Imaging related to magnetic resonance imaging reagents and markers outside the submitted work. Dr Chapin reported receiving personal fees from Blue Earth Diagnostics and Janssen Pharmaceuticals outside the submitted work. Dr G. L. Smith reported receiving grants from the National Cancer Institute outside of the submitted work. Dr B. D. Smith reported receiving grants from Varian Medical Systems and owning equity interest in Oncora Medical Systems outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flow Diagram of Patient Eligibility and Inclusion
EBRT indicates external beam radiation therapy; NCDB, National Cancer Database.
Figure 2.
Figure 2.. Survival of Patients Aged 70 Years and Younger With High-Risk Prostate Cancer, Based on Receipt of Definitive Therapy, Systemic Therapy Only, or No Treatment
See this image and copyright information in PMC

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