Increased Severity of Prostate Cancer Presentation in an Appalachian Cohort Compared to National Data

Abstract

Background: Prostate cancer is the second leading cause of cancer death among American men, with known disparities by geography, socioeconomic status, and access to care. Data on prostate cancer presentation in Appalachia are scarce.

Methods: We retrospectively reviewed 160 first-time transrectal ultrasound-guided prostate biopsies from 2022 to 2024 at a single Appalachian institution and compared them to 8776 positive biopsies from the PLCO trial. Gleason scores were grouped as 1 (≤ 6), 2/3 (7), 4 (8), and 5 (≥ 9). We used chi-square tests to compare grade distributions and PSA categories (< 4, 4-10, 10-20, > 20 ng/mL), Wilcoxon rank-sum tests for age and median PSA by grade, and sequential logistic regression (unadjusted; +age; +PSA+age) to identify independent predictors of Appalachian cohort membership.

Results: Appalachian patients were more likely to present with Grade 4 (19.1% vs. 7.9%) and Grade 5 disease (10.1% vs. 5.0%; χ² = 49.2, P < .001) and had older median age (e.g., Grade 1: 66 vs. 63 years, P = .0033) and higher median PSA (e.g., Grade 1: 8.6 vs. 5.7 ng/mL, P = .0001). PSA category distribution also differed (χ² = 44.8, P < .001). In fully adjusted models, Grade 4 (OR 2.54, P = .002) and Grade 5 (OR 2.80, P = .002) remained independent predictors of Appalachian cohort membership, while PSA was not (P = .280).

Conclusions: Appalachian patients exhibit a disproportionately high prevalence of advanced-grade prostate cancer that persists after accounting for age and PSA. Tailored, region-specific strategies are needed to enhance early detection and reduce persistent disparities in care.

Keywords: Appalachian region; Cancer screening; Gleason score; Health disparities; Prostatic neoplasms.