Adherence to American Cancer Society Guideline and Mortality in Men With Nonmetastatic Prostate Cancer

Abstract

Importance: Among men with nonmetastatic prostate cancer, prostate cancer-specific mortality (PCSM) is the leading cancer-related cause of death, and cardiovascular disease mortality (CVDM) is the most common non-cancer-related cause. The American Cancer Society (ACS) guideline for cancer survivors recommends avoiding obesity, engaging in regular physical activity, and following a healthy diet. While physical activity and body weight have been associated individually with lower mortality in patients with prostate cancer, the combined effect of all ACS guideline components remains unclear.

Objective: To examine the association between postdiagnosis ACS guideline concordance and mortality in nonmetastatic prostate cancer survivors.

Design, setting, and participants: This cohort study used data from the Cancer Prevention Study-II Nutrition Cohort and included men diagnosed with nonmetastatic prostate cancer between 1992 and 2003 and followed up from postdiagnosis survey completion until death or December 31, 2020. Analyses were conducted from March 2024 to February 2025.

Exposure: Prediagnosis and postdiagnosis ACS guideline concordance was scored from 0 to 8, with higher scores indicating greater adherence.

Main outcomes and measures: Mortality outcomes, including all-cause mortality (ACM), CVDM, and PCSM, were ascertained via National Death Index linkage. Cox proportional hazards regressions were used to estimate multivariable-adjusted hazard ratios (HRs) and 95% CIs across score categories (categorized as 0-3, 4, 5, and 6-8).

Results: Among 4232 prostate cancer survivors (median [IQR] age at diagnosis, 69 [65.0-73.0] years) followed for a median (IQR) of 14.1 (8.4-17.5) years, there were 3101 ACM outcomes (73.3%), 912 CVDM outcomes (21.6%), and 453 PCSM outcomes (10.7%). Higher postdiagnosis ACS score (ie, 6 to 8 vs 0 to 3) was associated with lower risk of ACM (HR, 0.77; 95% CI, 0.69-0.85; per 1-point increase: HR, 0.94; 95% CI, 0.91-0.96; P < .001) and CVDM (HR, 0.75; 95% CI, 0.63-0.91; per 1-point increase: HR, 0.93; 95% CI, 0.89-0.97; P = .001), while results for PCSM were not statistically significant. Results were similar when stratified by tumor aggressiveness. Patients who improved their guideline concordance after diagnosis (ie, a score of <5 to ≥5) or maintained high concordance (ie, a score of ≥5 to ≥5) had lower mortality risk compared with those who maintained low scores.

Conclusions and relevance: In this cohort study of men with nonmetastatic prostate cancer, higher postdiagnosis ACS guideline concordance and improvements in concordance were associated with lower ACM and CVDM, highlighting the importance of lifestyle modifications in prostate cancer survivorship.

Figure.. Study Flowchart of Exclusions to Identify Eligible Men Diagnosed With Prostate Cancer, 1992-2003

ACS indicates American Cancer Society; BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CPS-II, Cancer Prevention Study-II.