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Comparative Study
. 2020 Sep 1;3(9):e2018318.
doi: 10.1001/jamanetworkopen.2020.18318.

Comparison by Race of Conservative Management for Low-Risk and Intermediate-Risk Prostate Cancers in Veterans From 2004 to 2018

Ravi B Parikh  1   2   3   4   5 , Kyle W Robinson  1   3   4 , Sumedha Chhatre  1   2   3 , Elina Medvedeva  1   2 , John P Cashy  1   2 , Shika Veera  3 , Joshua M Bauml  1   3   4   5 , Tito Fojo  6 , Amol S Navathe  1   2   3   5 , S Bruce Malkowicz  1   3   4 , Ronac Mamtani  3   4 , Ravishankar Jayadevappa  1   2   3   4   5
Affiliations
Comparative Study

Comparison by Race of Conservative Management for Low-Risk and Intermediate-Risk Prostate Cancers in Veterans From 2004 to 2018

Ravi B Parikh et al. JAMA Netw Open. .

Abstract

Importance: Conservative management (ie, active surveillance or watchful waiting) is a guideline-based strategy for men with low-risk and intermediate-risk prostate cancer. However, use of conservative management is controversial for African American patients, who have worse prostate cancer outcomes compared with White patients.

Objective: To examine the association of African American race with the receipt and duration of conservative management in the Veterans Health Administration (VA), a large equal-access health system.

Design, setting, and participants: This cohort study used data from the VA Corporate Data Warehouse for 51 543 African American and non-Hispanic White veterans diagnosed with low-risk and intermediate-risk localized node-negative prostate cancer between January 1, 2004, and December 31, 2013. Men who did not receive continuous VA care were excluded. Data were analyzed from February 1 to June 30, 2020.

Exposures: All patients received either definitive therapy (ie, prostatectomy, radiation, androgen deprivation therapy) or conservative management (ie, active surveillance or watchful waiting).

Main outcomes and measures: Receipt of conservative management and (for patients receiving conservative management) time from diagnosis to definitive therapy.

Results: The median (interquartile range) age of the 51 543 veterans in our cohort was 65 (61-70) years, and 14 830 veterans (28.8%) were African American individuals. Compared with White veterans, African American veterans were more likely to have intermediate-risk disease (18 988 [51.7%] vs 8526 [57.5%]), 3 or more comorbidities (15 438 [42.1%] vs 7614 [51.3%]), and high disability-related or income-related needs (9078 [24.7%] vs 4614 [31.1%]). Overall, 20 606 veterans (40.0%) received conservative management. African American veterans with low-risk disease (adjusted relative risk, 0.95; 95% CI, 0.92-0.98; P < .001) and intermediate-risk disease (adjusted relative risk, 0.92; 95% CI, 0.87-0.97; P = .002) were less likely to receive conservative management than White veterans. Compared with White veterans, African American veterans with low-risk disease (adjusted hazard ratio, 1.71; 95% CI, 1.50-1.95; P < .001) and intermediate-risk disease (adjusted hazard ratio, 1.46; 95% CI, 1.27-1.69; P < .001) who received conservative management were more likely to receive definitive therapy within 5 years of diagnosis (restricted mean survival time [SE] at 5 years, 1679 [5.3] days vs 1740 [2.4] days; P < .001).

Conclusions and relevance: In this study, conservative management was less commonly used and less durable for African American veterans than for White veterans. Prospective trials should assess the comparative effectiveness of conservative management in African American men with prostate cancer.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Parikh reported receiving stock options and personal fees from GNS Healthcare and personal fees from the Cancer Study Group outside the submitted work. Dr Robinson reported serving on the advisory board for Bayer outside the submitted work. Dr Bauml reported receiving grants and personal fees from Merck, Janssen Pharmaceuticals, AstraZeneca, and Takeda; nonfinancial support in the form of a drug for a trial from Incyte; grants from Carevive Systems, Novartis, Bayer, and Amgen; personal fees from Bristol Myers Squibb, Celgene, Genentech, Guardant Health, Boehringer Ingelheim, Regeneron, Inivata, and Ayala outside the submitted work. Dr Navathe reported receiving grants from the Hawaii Medical Service Association, Anthem Public Policy Institute, the Commonwealth Fund, Oscar Health, Cigna, the Robert Wood Johnson Foundation, the Donaghue Foundation, the Pennsylvania Department of Health, Ochsner Health System, United Healthcare, and Blue Cross Blue Shield of North Carolina; receiving personal fees from Navvis Healthcare, Agathos, Navahealth, University Health System–Singapore, the Social Security Administration–France, Elsevier Press, Medicare Payment Advisory Commission, the Cleveland Clinic, Embedded Healthcare; and serving as a noncompensated board member for Integrated Services outside the submitted work. Dr Mamtani reported receiving personal fees from Seattle Genetics/Astellas and Flatiron outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Time to Receipt of Definitive Therapy Among Veterans With Low-Risk and Intermediate-Risk Localized Prostate Cancer Who Received Conservative Management
Figure 2.
Figure 2.. Time to Definitive Therapy Among Veterans With Low-Risk and Intermediate-Risk Localized Prostate Cancer Who Received Conservative Management, Stratified by Active Surveillance (AS) vs Watchful Waiting (WW)
See this image and copyright information in PMC

References

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