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. 2024 Nov 4;7(11):e2445505.
doi: 10.1001/jamanetworkopen.2024.45505.

Racial and Ethnic Differences in Prostate Cancer Epidemiology Across Disease States in the VA

Shannon R Stock  1   2 , Michael T Burns  1 , Justin Waller  1 , Amanda M De Hoedt  1 , Joshua A Parrish  1 , Sameer Ghate  3 , Jeri Kim  3 , Irene M Shui  3 , Stephen J Freedland  1   4
Affiliations

Racial and Ethnic Differences in Prostate Cancer Epidemiology Across Disease States in the VA

Shannon R Stock et al. JAMA Netw Open. .

Abstract

Importance: Prostate cancer (PC) care has evolved rapidly as a result of changes in prostate-specific antigen testing, novel imaging, and newer treatments. The impact of these changes on PC epidemiology and racial disparities across disease states remains underexplored.

Objective: To characterize racial and ethnic differences in the epidemiology of PC states, including nonmetastatic hormone-sensitive PC (nmHSPC), metastatic HSPC (mHSPC), nonmetastatic castration-resistant PC (nmCRPC), and metastatic CRPC (mCRPC).

Design, setting, and participants: This is a retrospective, population-based cohort study of male US veterans aged 40 years and older with known race and ethnicity and no non-PC malignant neoplasm before study entry receiving care through the Veterans Health Administration. The study period was from 2012 to 2020, with follow-up through 2021. To identify active users, data capture included visits 18 months before and after the study period. Data analysis was performed from March to August 2023.

Exposure: Self-identified race and ethnicity, classified as Black, White, or Hispanic.

Main outcomes and measures: The primary outcomes were annual age-adjusted incidence rates (IRs) and point prevalence for PC states by race and ethnicity. Trends were evaluated using joinpoint regression. Time to disease progression or death was estimated using nonparametric cumulative incidence. Competing risk models adjusted for age assessed the association of race and ethnicity on disease progression.

Results: The study included 6 539 001 veterans (median [IQR] age, 65 [56-74] years), of whom 476 227 had PC (median [IQR] age, 69 [63-75] years). IRs varied by time frame and disease state. Across all states and years, the relative risk among Black vs White patients ranged from 2.09 (95% CI, 2.01-2.18; P < .001) for nmHSPC in 2012 to 4.12 (95% CI, 3.39-5.02; P < .001) for nmCRPC in 2017. In nmHSPC, hazard ratios for progression to mHSPC and nmCRPC were 1.36 (95% CI, 1.33-1.40) and 1.60 (95% CI, 1.51-1.70), respectively, for Black patients and 1.38 (95% CI, 1.31-1.45) and 1.55 (95% CI, 1.40-1.72), respectively, for Hispanic patients vs White patients. In contrast, in mCRPC, the hazard ratio for death was lower for Black (0.84; 95% CI, 0.81-0.88) and Hispanic (0.76; 95% CI, 0.69-0.83) patients compared with White patients.

Conclusions and relevance: This cohort study of veterans found that Black patients had more than 2-fold higher incidence of all disease states vs White patients. Progression risk was higher for Black and Hispanic patients in early-stage disease, but lower in later disease stages. Despite equal access, Black patients disproportionately experience PC, although progression risks relative to White patients differed according to disease state.

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Conflict of interest statement

Conflict of Interest Disclosures: Mr Burns reported receiving grants or contracts from Ferring, Janssen, LungLife AI, Pfizer, Blue Earth, Exact Sciences, Astellas Pharma, Delfi Diagnostics, Guardant Health, Photocure, AstraZeneca, Reinvestment Partners, Prostatype Genomics, Novartis, Myovant Sciences, Genomic Health, Myriad Genetics, Diasorin, MDxHealth, and VIR Biotechnology outside the submitted work. Ms De Hoedt reported receiving grants from Janssen, Astellas Pharma, AstraZeneca, Prostatype Genomics, and Novartis outside the submitted work. Mr Parrish reported receiving grants from Ferring, Janssen, LungLife AI, Pfizer, Blue Earth Diagnostics, Exact Sciences, Astellas Pharma, Delfi Diagnostics, Guardant Health, Photocure, AstraZeneca Pharmaceuticals, Reinvestment Partners, Prostatype Genomics, Novartis, Myovant Sciences, Genomic Health, Myriad Genetics, Diasorin, MDxHealth, and VIR Biotechnology outside the submitted work. Dr Ghate reported being an employee of Merck & Co, Inc, and owning stocks during the conduct of the study. Dr Kim reported being employed by Merck & Co, Inc, and holding company stock while engaged in the work submitted. Dr Shui reported being a Merck employee during the conduct of the study and holding company stock outside the submitted work. Dr Freedland reported receiving personal fees from Merck, Astra Zeneca, Astellas, Janssen, Pfizer, Bayer, Novartis, Eli Lilly, and Sanofi outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Enrollment Flowchart
Patients who transitioned during the study period are counted in all relevant disease states. mCRPC indicates metastatic castrate-resistant prostate cancer; mHSPC, metastatic hormone–sensitive prostate cancer; nmCRPC, nonmetastatic castrate-resistant prostate cancer; nmHSPC, nonmetastatic hormone-sensitive prostate cancer.
Figure 2.
Figure 2.. Age-Adjusted Incidence Rates (per 100 000 Person-Years) by Race, Ethnicity, Disease State, and Year
The dots represent the observed rates; the solid line represents model-based estimates obtained by the joinpoint analysis, with the annual percentage change (APC) noted for each line segment. mCRPC indicates metastatic castrate-resistant prostate cancer; mHSPC, metastatic hormone–sensitive prostate cancer; nmCRPC, nonmetastatic castrate-resistant prostate cancer; and nmHSPC, nonmetastatic hormone-sensitive prostate cancer. aIndicates that the APC is significantly different from 0 at α = .05.
Figure 3.
Figure 3.. Cumulative Incidence Curves for the Time From Diagnosis of a Disease State to Disease Progression or Death as Competing Risks
mCRPC indicates metastatic castrate-resistant prostate cancer; mHSPC, metastatic hormone–sensitive prostate cancer; nmCRPC, nonmetastatic castrate-resistant prostate cancer; nmHSPC, nonmetastatic hormone-sensitive prostate cancer. aCumulative incidence curve estimates for mCRPC and nmCRPC are less than 3% at all time points; note the y-axis ranges from 0 to 0.4.
See this image and copyright information in PMC

Comment in

  • doi: 10.1001/jamanetworkopen.2024.45522

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