Factors influencing prostate cancer treatment decisions for African American and white men

Determinants of active surveillance uptake in a diverse population-based cohort of men with low-risk prostate cancer: The Treatment Options in Prostate Cancer Study (TOPCS)

BACKGROUND

Active surveillance (AS) is the preferred strategy for low-risk prostate cancer (LRPC); however, limited data on determinants of AS adoption exist, particularly among Black men.

METHODS

Black and White newly diagnosed (from January 2014 through June 2017) patients with LRPC ≤75 years of age were identified through metro-Detroit and Georgia population-based cancer registries and completed a survey evaluating factors influencing AS uptake.

RESULTS

Among 1688 study participants, 57% chose AS (51% of Black participants, 61% of White) over definitive treatment. In the unadjusted analysis, patient factors associated with initial AS uptake included older age, White race, and higher education. However, after adjusting for covariates, none of these factors was significant predictors of AS uptake. The strongest determinant of AS uptake was the AS recommendation by a urologist (adjusted prevalence ratio, 6.59, 95% CI, 4.84-8.97). Other factors associated with the decision to undergo AS included a shared patient-physician treatment decision, greater prostate cancer knowledge, and residence in metro-Detroit compared with Georgia. Conversely, men whose decision was strongly influenced by the desire to achieve "cure" or "live longer" with treatment and those who perceived their LRPC diagnosis as more serious were less likely to choose AS.

CONCLUSIONS

In this contemporary sample, the majority of patients with newly diagnosed LRPC chose AS. Although the input from their urologists was highly influential, several patient decisional and psychological factors were independently associated with AS uptake. These data shed new light on potentially modifiable factors that can help further increase AS uptake among patients with LRPC.

Influential Factors Impacting Treatment Decision-making and Decision Regret in Patients with Localized or Locally Advanced Prostate Cancer: A Systematic Literature Review

CONTEXT

Treatment decision-making (TDM) for patients with localized (LPC) or locally advanced (LAPC) prostate cancer is complex, and post-treatment decision regret (DR) is common. The factors driving TDM or predicting DR remain understudied.

OBJECTIVE

Two systematic literature reviews were conducted to explore the factors associated with TDM and DR.

EVIDENCE ACQUISITION

Three online databases, select congress proceedings, and gray literature were searched (September 2022). Publications on TDM and DR in LPC/LAPC were prioritized based on the following: 2012 onward, ≥100 patients, journal article, and quantitative data. The Preferred Reporting Items Reviews and Meta-analyses guidelines were followed. Influential factors were those with p < 0.05; for TDM, factors described as "a decision driver", "associated", "influential", or "significant" were also included. The key factors were determined by number of studies, consistency of evidence, and study quality.

EVIDENCE SYNTHESIS

Seventy-five publications (68 studies) reported TDM. Patient participation in TDM was reported in 34 publications; overall, patients preferred an active/shared role. Of 39 influential TDM factors, age, ethnicity, external factors (physician recommendation most common), and treatment characteristics/toxicity were key. Forty-nine publications reported DR. The proportion of patients experiencing DR varied by treatment type: 7-43% (active surveillance), 12-57% (radical prostatectomy), 1-49% (radiotherapy), 28-49% (androgen-deprivation therapy), and 21-47% (combination therapy). Of 42 significant DR factors, treatment toxicity (sexual/urinary/bowel dysfunction), patient role in TDM, and treatment type were key.

CONCLUSIONS

The key factors impacting TDM were physician recommendation, age, ethnicity, and treatment characteristics. Treatment toxicity and TDM approach were the key factors influencing DR. To help patients navigate factors influencing TDM and to limit DR, a shared, consensual TDM approach between patients, caregivers, and physicians is needed.

PATIENT SUMMARY

We looked at factors influencing treatment decision-making (TDM) and decision regret (DR) in patients with localized or locally advanced prostate cancer. The key factors influencing TDM were doctor's recommendation, patient age/ethnicity, and treatment side effects. A shared, consensual TDM approach between patients and doctors was found to limit DR.

Association of race/ethnicity and patient care experiences with receipt of definitive treatment among prostate cancer survivors: a SEER-CAHPS study

PURPOSE

This study aimed to evaluate the association of race/ethnicity, patient care experiences (PCEs), and receipt of definitive treatment and treatment modality among older adults in the United States (US) with localized prostate cancer (PCa).

METHODS

Using Surveillance, Epidemiology and End Results dataset linked to Medicare Consumer Assessment of Healthcare Providers and Systems (SEER-CAHPS) for 2007-2015, we identified men aged ≥ 65 years who completed a CAHPS survey within one year before and one year after PCa diagnosis. Associations of race/ethnicity (non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic, non-Hispanic Asian (NHA), and other) and of interactions between race/ethnicity and PCEs (getting needed care, getting care quickly, doctor communication, and care coordination) with the receipt of definitive PCa treatment and treatment modality within 3 and 6 months of diagnosis were examined using logistic regressions.

RESULTS

Among 1,438 PCa survivors, no racial/ethnic disparities in the receipt of definitive treatment were identified. However, NHB patients were less likely to receive surgery (vs. radiation) within 3 and 6 months of PCa diagnosis than NHW patients (OR 0.397, p = 0.006 and OR 0.419, p = 0.005), respectively. Among NHA patients, a 1-point higher score for getting care quickly was associated with lower odds (OR 0.981, p = 0.043) of receiving definitive treatment within 3 months of PCa diagnosis, whereas among NHB patients, a 1-point higher score for doctor communication was associated with higher odds (OR 1.023, p = 0.039) of receiving definitive treatment within 6 months of PCa diagnosis.

DISCUSSION

We observed differential associations between PCEs and receipt of definitive treatment based on patient race/ethnicity. Further research is needed to explore these associations.

Prostate Cancer: Under-representation of African American Men in Research Studies Used in the Latest NCCN Guidelines

OBJECTIVE

To evaluate racial data in studies used in current NCCN prostate cancer guidelines. These guidelines represent the latest information that informs clinical practice. Prostate cancer disproportionately affects mortality in Black patients compared to White patients at a 2.1-fold higher death rate. However, this racial disparity is not accounted for when including patients in research.

METHODS

The studies referenced in the latest NCCN guidelines were evaluated for inclusion of racial demographics, and whether they properly account for the higher mortality rate of prostate cancer seen in Black patients. We then analyzed topics within prostate cancer.

RESULTS

After application of exclusion criteria, 547 of 878 studies were included for analysis; of those, only 32.4% included demographic data. Overall, Black patients accounted for 472,476 (12.8%) of total patients, while 3,023,007 (81.7%) patients were White. These findings were consistent with specific areas including risk stratification (12% vs 75%), imaging and staging (11% vs 80%), treatment (16% vs 81%), recurrence (15% vs 73%), castration-sensitive prostate cancer (9% vs 84%), castration-resistant prostate cancer (8% vs 73%), and metastatic bone disease (7% vs 84%).

CONCLUSION

Our analysis showed consistently that although the guidelines utilize the best research, such studies often do not report racial demographics or have patient populations that do not reflect racial differences in mortality of prostate cancer. Our study questions the generalization of these studies to Black patients. Future research should emphasize inclusion of racial demographics and recruit appropriately representative study cohorts.

Prostate-specific antigen response and clinical progression-free survival in Black and White men with chemotherapy-naïve metastatic castration-resistant prostate cancer treated with enzalutamide in a real-world setting

BACKGROUND

In the United States, Black men have a higher incidence of prostate cancer (PC)-related mortality than men of other races. Several real-world studies in advanced PC suggest, however, that Black men respond better to novel hormonal therapies than White men. Data on treatment responses to enzalutamide by race are limited. We assessed real-world prostate-specific antigen (PSA) response and clinical progression-free survival (cPFS) of Black vs. White men with chemotherapy-naïve PC treated with enzalutamide.

METHODS

This retrospective cohort study included patients with PC who initiated enzalutamide treatment from 2014 to 2018 in the IntrinsiQ Specialty Solutions™ database, a collection of electronic medical records from community urology practices. Index date was the date of the first prescription for enzalutamide, used as a proxy for metastatic castration-resistant PC (mCRPC). Patients who had undergone chemotherapy and/or abiraterone therapy were excluded. Kaplan-Meier and Cox models adjusted for baseline characteristics were used to estimate PSA response and cPFS by race.

RESULTS

The study included 214 Black and 1332 White men with chemotherapy-naïve PC presumed to have mCRPC based on the enzalutamide indication during the study period. Black men were younger and had higher baseline median PSA levels than White men. Enzalutamide therapy duration, follow-up time, and number of post-index PSA tests were similar between races. In multivariable analyses, the risk of patients achieving a ≥ 50% PSA decline was similar, whereas a numerically higher trend of ≥90% PSA decline was observed in Black men (HR 1.23; 95% CI 0.93-1.62 [P = 0.14]). In the multivariable analysis, Black men had significantly better cPFS (HR 0.82; 95% CI 0.68-0.98 [P = 0.03]).

CONCLUSIONS

Black and White men with presumed chemotherapy-naïve mCRPC had similar PSA responses when treated with enzalutamide, but Black men had better cPFS than White men. Further research is warranted to validate these findings.

Outcome Quality After Colorectal Cancer Resection in Certified Colorectal Cancer Centers–Patient-Reported and Short-Term Clinical Outcomes

BACKGROUND

In this observational study, patient-reported outcomes and short-term clinical outcome parameters in patients with colorectal cancer were studied 12 months after the start of treatment. Outcomes were also compared across German Certified Colorectal Cancer Centres.

METHODS

Data were collected from 4239 patients with colorectal cancer who had undergone elective tumor resection in one of 102 colorectal cancer centers and had responded to a quality-of-life questionnaire before treatment (EORTC QLQ-C30 and -CR29). 3142 (74.1%) of these patients completed a post-treatment questionnaire 12 months later. Correlation analyses were calculated and case-mix adjusted comparisons across centers were made for selected patient-reported outcomes, anastomotic insufficiency, and 30-day-mortality.

RESULTS

At 12 months, mild improvements were seen in mean quality-of-life scores (66 vs. 62 points), constipation (16 vs. 19), and abdominal pain (15 vs. 17). Worsening was seen in physical function (75 vs. 82) and pain (22 vs. 19). Better patient-reported outcomes at 12 months were associated with better scores before treatment. Better results in at least three of the five scores were associated with male sex, higher educational level, higher age, and private health insurance. Major worsening of fecal incontinence was seen among patients with rectal cancer without a stoma. The largest differences across centers were found with respect to physical function. Anastomotic insufficiency was found in 4.3% of colon cancer patients and 8.2% of rectal cancer patients. 1.9% of patients died within 30 days after their resection.

CONCLUSION

Clinicians can use these findings to identify patients at higher risk for poorer patient-reported outcomes. The differences among cancer centers that were found imply that measures for quality improvement would be desirable.

Racial disparities in Black men with prostate cancer: A literature review

Black men are disproportionately affected by prostate cancer (PCa), with earlier presentation, more aggressive disease, and higher mortality rates versus White men. Furthermore, Black men have less access to PCa treatment and experience longer delays between diagnosis and treatment. In this review, the authors discuss the factors contributing to racial disparities and present solutions to improve access to care and increase clinical trial participation among Black men with PCa. Racial disparities observed among Black men with PCa are multifaceted, evolving from institutional racism. Cultural factors include generalized mistrust of the health care system, poor physician-patient communication, lack of information on PCa and treatment options, fear of PCa diagnosis, and perceived societal stigma of the disease. In the United States, geographic trends in racial disparities have been observed. Economic factors, e.g., cost of care, recovery time, and cancer debt, play an important role in racial disparities observed in PCa treatment and outcomes. Racial diversity is often lacking in genomic and precision medicine studies. Black men are largely underrepresented in key phase 3 PCa trials and may be less willing to enroll in clinical trials due to lack of awareness, lack of diversity in clinical trial research teams, and bias of health care providers to recommend clinical research. The authors propose solutions to address these factors that include educating clinicians and institutions on the barriers Black men experience, increasing the diversity of health care providers and clinical research teams, and empowering Black men to be involved in their treatment, which are keys to creating equity for Black men with PCa. LAY SUMMARY: Prostate cancer negatively affects Black men more than men of other races. The history of segregation and mistreatment in the health care system may contribute to mistrust among Black men. Outcomes are worse for Black men because they are less likely to be screened or to receive treatment for prostate cancer. Black men also are unlikely to participate in clinical research, making it difficult for investigators to understand how Black men are affected by prostate cancer. Suggestions for addressing these differences include teaching physicians and nurses about the issues Black men experience getting treatment and improving how Black men get information on prostate cancer.

Deconstructing, Addressing, and Eliminating Racial and Ethnic Inequities in Prostate Cancer Care

CONTEXT

Men of African ancestry have demonstrated markedly higher rates of prostate cancer mortality than men of other races and ethnicities around the world. In fact, the highest rates of prostate cancer mortality worldwide are found in the Caribbean and Sub-Saharan West Africa, and among men of African descent in the USA. Addressing this inequity in prostate cancer care and outcomes requires a focused research approach that creates durable solutions to address the structural, social, environmental, and health factors that create racial disparities in care and outcomes.

OBJECTIVE

To introduce a conceptual model for evaluating racial inequities in prostate cancer care to facilitate the development of translational research studies and interventions.

EVIDENCE ACQUISITION

A collaborative review of literature relevant to racial inequities in prostate cancer care and outcomes was performed. Existing literature was used to highlight various components of the conceptual model to inform future research and interventions toward equitable care and outcomes.

EVIDENCE SYNTHESIS

Racial inequities in prostate cancer outcomes are driven by a series of structural and social determinants of health that impact exposures, mediators, and outcomes. Social determinants of equity, such as laws/policies, economic systems, and structural racism, affect the inequitable access to environmental and neighborhood exposures, in addition to health care access. Although the incidence disparity remains problematic, various studies have demonstrated parity in outcomes when social and health factors, such as access to equitable care, are normalized. Few studies have tested interventions to reduce inequities in prostate cancer among Black men.

CONCLUSIONS

Worldwide, men of African ancestry demonstrate worse outcomes in prostate cancer, a phenomenon driven largely by social factors that inform biologic, environmental, and health care risks. A conceptual model was presented that organizes the many factors that influence prostate cancer incidence and mortality. Within that framework, we must understand the current state of inequities in clinical prostate cancer practice, the optimal state of what equitable practice would be, and how achieving equity in prostate cancer care balances costs, benefits, and harms. More robust characterization of the sources of prostate cancer inequities should inform testing of ambitious and innovative interventions as we work toward equity in care and outcomes.

PATIENT SUMMARY

Men of African ancestry demonstrate the highest rates of prostate cancer mortality, which may be reduced through social interventions. We present a framework for formalizing the identification of the drivers of prostate cancer inequities to facilitate the development of interventions and trials to eradicate them.

A constructivist grounded theory study on decision-making for treatment choice among Black African and Black Caribbean prostate cancer survivors

OBJECTIVE

Despite Black African (BA) and Black Caribbean (BC) men having a disproportionately high risk (1 in 4) of developing prostate cancer (CaP), there is limited understanding of their decision-making for treatment choice. This study explored decision-making for treatment choice among BA/BC men treated for CaP.

METHODS

Using constructivist grounded theory, face-to-face, Skype and telephone interviews were conducted with 25 Black men (8 BA, 17 BC) recruited in England between October 2016 and March 2018. Data were analysed using constant comparison until saturation was achieved.

RESULTS

Data analysis yielded three broad categories: 'coming to terms with the prostate cancer diagnosis', 'getting empowerment through information-seeking' and 'choosing a treatment option'. Priority for survival substantially motivated BA/BC men to take up radical treatment for their CaP. However, decision-making for a particular treatment option was a more complex process which was shaped by an intersection between biological, behavioural, medical, personal and cultural factors.

CONCLUSIONS

Healthcare providers need to consider the complexity of decision-making process for CaP treatment among BA/BC men and tailor cancer care services to reflect cultural sensitivity and person-centredness. This could potentially minimise treatment decision regrets and improve men's psychological wellbeing along the CaP survivorship pathway.

Pentz R. Prostate Cancer: Community Education and Disparities in Diagnosis and Treatment

Prostate cancer remains the leading diagnosed cancer and the second leading cause of death among American men. Despite improvements in screening modalities, diagnostics, and treatment, disparities exist among Black men in this country. The primary objective of this systematic review is to describe the reported disparities in screening, diagnostics, and treatments as well as efforts to alleviate these disparities through community and educational outreach efforts. Critical review took place of retrospective, prospective, and socially descriptive data of English language publications in the PubMed database. Despite more advanced presentation, lower rates of screening and diagnostic procedures, and low rates of trial inclusion, subanalyses have shown that various modalities of therapy are quite effective in Black populations. Moreover, patients treated on prospective clinical trials and within equal-access care environments have shown similar outcomes regardless of race. Additional prospective studies and enhanced participation in screening, diagnostic and genetic testing, clinical trials, and community-based educational endeavors are important to ensure equitable progress in prostate cancer for all patients. IMPLICATIONS FOR PRACTICE: Notable progress has been made with therapeutic advances for prostate cancer, but racial disparities continue to exist. Differing rates in screening and utility in diagnostic procedures play a role in these disparities. Black patients often present with more advanced disease, higher prostate-specific antigen, and other adverse factors, but outcomes can be attenuated in trials or in equal-access care environments. Recent data have shown that multiple modalities of therapy are quite effective in Black populations. Novel and bold hypotheses to increase inclusion in clinical trial, enhance decentralized trial efforts, and enact successful models of patient navigation and community partnership are vital to ensure continued progress in prostate cancer disparities.

A narrative review of sociodemographic risk and disparities in screening, diagnosis, treatment, and outcomes of the most common extrathoracic malignancies in the United States

There is a well-established association between multiple sociodemographic risk factors and disparities in cancer care. These risk factors include minority race and ethnicity, low socioeconomic status (SES) including low income and education level, non-English primary language, immigrant status, and residential segregation, and distance to facilities that deliver cancer care. As cancer care advances, existing disparities in screening, treatment, and outcomes have become more evident. Lung cancer remains the most common and fatal malignancy in the United States, with breast, colorectal, and prostate cancer being the three most common and deadly extrathoracic malignancies. Achieving the best outcomes for patients with these malignancies relies on strong physician-patient relationships leading to robust screening, early diagnosis, and early referral to facilities that can deliver multidisciplinary care and multimodal therapy. It is likely that challenges experienced in developing patient trust and understanding, providing access to screening, and building referral pipelines for definitive therapy in lung cancer care to vulnerable populations are paralleled by those in extrathoracic malignancies. Likewise, progress made in delivering optimal care to all patients across sociodemographic and geographic barriers can serve as a roadmap. Therefore, we provide a narrative review of current disparities in screening, treatment, and outcomes for patients with breast, prostate, and colorectal malignancies.

Identifying Risk Profiles of Malignant Prostate Cancer Surgical Delay Using a Person-Centered Approach to Understand Prostate Cancer Disparities: The Constellation of Health Determinants Using Latent Class Analysis on Cancer Registry Data

Surgical prostate cancer (PCa) treatment delay (TD) may increase the likelihood of recurrence of disease, and influence quality of life as well as survival disparities between Black and White men. We used latent class analysis (LCA) to identify risk profiles in localized, malignant PCa surgical treatment delays while assessing co-occurring social determinants of health. Profiles were identified by age, marital status, race, county of residence (non-Appalachian or Appalachian), and health insurance type (none/self-pay, public, or private) reported in the Tennessee Department of Health cancer registry from 2005 to 2015 for adults ≥18 years (N = 18,088). We identified three risk profiles. The highest surgical delay profile (11% of the sample) with a 30% likelihood of delaying surgery >90 days were young Black men, <55 years old, living in a non-Appalachian county, and single/never married, with a high probability of having private health insurance. The medium surgical delay profile (46% of the sample) with a 21% likelihood of delay were 55–69 years old, White, married, and having private health insurance. The lowest surgical delay profile (42% of the sample) with a 14% likelihood of delay were ≥70 years with public health insurance as well as had a high probability of being White and married. We identified that even with health insurance coverage, Blacks living in non-Appalachian counties had the highest surgical delay, which was almost double that of Whites in the lowest delay profile. These disparities in PCa surgical delay may explain differences in health outcomes in Blacks who are most at-risk.

Outcomes of Black men with prostate cancer treated with radiation therapy in the Veterans Health Administration

BACKGROUND

Population-based studies demonstrate that Black men in the United States have an increased risk of death from prostate cancer. Determinants of racial disparities are multifactorial, including socioeconomic and biologic factors.

METHODS

The authors conducted a pooled analysis of patients derived from 152 centers within the Veterans Health Administration. The cohort included men who had nonmetastatic prostate diagnosed between 2001 and 2015 and received definitive radiation therapy. The primary endpoint was prostate cancer-specific mortality (PCSM). Secondary endpoints included all-cause mortality (ACM) and the time from a prostate-specific antigen level ≥4 ng/mL to biopsy and radiation therapy. A Cox regression model was performed to adjust for differences between clinical parameters.

RESULTS

Among the 31,131 patients included in the cohort, 9584 (30.8%) were Black. The 10-year cumulative incidence of death from prostate cancer was lower in Black men compared with White men (4.0% vs 4.8%; P = .004). In a competing risk model, Black race was associated with a decreased risk of PCSM (subdistribution hazard ratio, 0.79; 95% CI, 0.69-0.92; P = .002). Similarly, the 10-year cumulative incidence of death from any cause was lower in Black men (27.6% vs 31.8%; P < .001). In multivariable analysis, Black men had a 10% decreased risk of ACM (hazard ratio, 0.90; 95% CI, 0.85-0.95; P < .001).

CONCLUSIONS

The current results indicate relatively lower PCSM and ACM among Black men who were included in a large Veterans Health Administration cohort and received radiation therapy as primary treatment for nonmetastatic prostate cancer. There is an ongoing need to continue to understand and mitigate the factors associated with disparities in health care outcomes.