Is prostate cancer stage migration continuing for black men in the PSA era?

Rates and trends in stage-specific prostate cancer incidence by age and race/ethnicity, 2000-2017

BACKGROUND

The 2008 and 2012 United States Preventive Services Task Force (USPSTF) recommendations against prostate-specific antigen (PSA) screening have led to changes in the incidence pattern of prostate cancer. We sought to examine rates and trends in stage-specific prostate cancer incidence by age and race/ethnicity using the most recent data obtained from Surveillance, Epidemiology, and End Results (SEER) program.

METHODS

SEER*Stat version 8.3.6 was used to analyze annual prostate cancer incidence rates between 2000 and 2017 according to the SEER summary stage, age group, and race/ethnicity group. Incidence rates per 100,000 men were calculated and age-adjusted to 2000 US standard population. Annual percentage change (APC) was performed to identify the trend in prostate cancer incidence.

RESULTS

Between 2008 and 2012, trends in incidence of overall and localized prostate cancer significantly declined in comparison with between 2000 and 2007 (APC, -5.4 and -6.0, respectively). However, there was an increase in the incidence rate of both overall and localized prostate cancer from 2014 to 2017 (43.3-46 and 34-34.9 per 100,000 men, respectively). The incidence of regional prostate cancer significantly increased between 2013 and 2017 (5.9-6.8 per 100,000 men; APC, 4.3). Distant disease incidence increased continually between 2008 and 2012 (2.9-3.3 per 100,000 men; APC, 2.3) and between 2013 and 2017 (3.4-4.3 per 100,000 men; APC, 6.0). In addition, these increases in incidence occurred in men of all stratified age and race/ethnicity groups, except for men aged <50 years and American Indian/Alaska Native men.

CONCLUSION

This study demonstrates that the longer-term effects of USPSTF recommendations against PSA screening may have resulted in a reversal of downtrend in prostate cancer incidence, as incidence rates of overall and localized prostate cancer gradually increased from 2014 to 2017. Meanwhile, the trend in stage migration toward advanced disease increased incrementally.

The Will Rogers phenomenon, breast cancer and race

BACKGROUND

The Will Rogers phenomenon [WRP] describes an apparent improvement in outcome for patients' group due to tumor grade reclassification. Staging of cancers is important to select appropriate treatment and to estimate prognosis. The WRP has been described as one of the most important biases limiting the use of historical cohorts when comparing survival or treatment. The main purpose of this study is to assess whether the WRP exists with the move from the AJCC 7th to AJCC 8th edition in breast cancer [BC] staging, and if racial differences are manifested in the expression of the WRP.

METHODS

This is a retrospective analysis of 300 BC women (2007-2017) at an academic medical center. Overall survival [OS] and disease-free survival [DFS] was estimated by Kaplan-Meier analysis. Bi and multi-variate Cox regression analyses was used to identify racial factors associated with outcomes.

RESULTS

Our patient cohort included 30.3% Caucasians [Whites] and 69.7% African-Americans [Blacks]. Stages I, II, III, and IV were 46.2, 26.3, 23.1, and 4.4% of Whites; 28.7, 43.1, 24.4, and 3.8% of Blacks respectively, in anatomic staging (p = 0.043). In prognostic staging, 52.8, 18.7, 23, and 5.5% were Whites while 35, 17.2, 43.5, and 4.3% were Blacks, respectively (p = 0.011). A total of Whites (45.05% vs. 47.85%) Blacks, upstaged. Whites (16.49% vs. 14.35%) Blacks, downstaged. The remaining, 38.46 and 37.79% patients had their stages unchanged. With a median follow-up of 54 months, the Black patients showed better stage-by-stage 5-year OS rates using 8th edition compared to the 7th edition (p = 0.000). Among the Whites, those who were stage IIIA in the 7th but became stage IB in the 8th had a better prognosis than stages IIA and IIB in the 8th (p = 0.000). The 8th showed complex results (p = 0.176) compared to DFS estimated using the 7th edition (p = 0.004).

CONCLUSION

The WRP exists with significant variability in the move from the AJCC 7th to the 8th edition in BC staging (both White and Black patients). We suggest that caution needs to be exercised when results are compared across staging systems to account for the WRP in the interpretation of the data.

Helping Men Find Their Way: Improving Prostate Cancer Clinic Attendance via Patient Navigation

Navigation programs aim to help patients overcome barriers to cancer diagnosis and treatment. Missed clinic appointments have undesirable effects on the patient, health system, and society, and treatment delays have been shown to result in inferior surgical cure rates for men with prostate cancer (CaP). We sought to measure the impact of patient navigation on CaP clinic adherence. Patient navigators contacted patients prior to their first encounter for known or suspected CaP between 7/1/2016 and 6/30/2017. Encounters from 7/1/2014 to 6/30/2015 were used as a historical control. Patient-variables were analyzed including age, health insurance status, home address, zip code, race, ethnicity, and referring primary care clinic. Encounter-level variables included diagnosis (categorized as known or suspected CaP), date of appointment, type of appointment [new vs. return], and provider. The associations between several factors including navigation contact and these variables with missed appointment were analyzed using generalized linear mixed effects multivariate logistic regression. A total of 2854 scheduled clinic encounters from 986 unique patients were analyzed. Patient navigation resulted in a lower missed appointment rate (8.8% vs. 13.9%, OR = 0.64, IQR 0.44-0.93, p = 0.02 on multivariable analysis). Lack of health insurance (OR = 13.18 [5.13-33.83]), suspected but not confirmed CaP diagnosis (OR = 7.44 [4.85-11.42]), and Black (1.97 [1.06-3.65]) or Hispanic (OR = 3.61 [1.42-9.16]) race, were associated with missed appointment. Implementation of patient navigation reduced missed appointment rates for CaP related ambulatory encounters. Identifying risk factors for missed appointment may aid in targeting navigation services to those most likely to benefit from this intervention.

Associations of Prostate-Specific Antigen (PSA) Testing in the US Population: Results from a National Cross-Sectional Survey

Prostate-specific antigen (PSA) testing is one of the standard screening methods for prostate cancer (PC); however, a high proportion of men with abnormal PSA findings lack evidence for PC and may undergo unnecessary treatment. Furthermore, little is known about the prevalence of PSA testing for US men, after the US Preventive Services Task Force (USPSTF) recommended against routine PSA screening in 2012. Our objectives were to: (1) examine the self-reported patterns of PSA testing following a change in the USPSTF prostate cancer screening recommendations and (2) to determine the associated socio-demographic factors. Data were from the 2010 and 2015 National Health Interview Surveys. Men were ages ≥ 40 years and responded to the question "Ever had a PSA test?". Multivariable logistic regression was used to examine PSA testing prevalence in 2010 and 2015, and their associated socio-demographic factors. The analytic sample contained 15,372 men. A majority (75.2%) identified as non-Hispanic (NHW) and 14.2% were foreign-born. Those surveyed in 2015 were less likely to report ever having had a PSA test when compared to those in 2010. Compared to US-born and older NHW men, PSA testing was statistically significantly lower among foreign-born men and men belonging to all other racial categories. Fewer men reported PSA testing following the USPSTF 2012 recommendations. Associated socio-demographic factors included nativity, age, race/ethnicity, educational attainment and type of health insurance. Further studies are required to elucidate our findings and their health implications for the US native and foreign-born population.

A discussion on controversies and ethical dilemmas in prostate cancer screening

Prostate cancer (PCa) is one of the the most common cancers in men. A blood test called prostate-specific antigen (PSA) has a potential to pick up this cancer very early and is used for screening of this disease. However, screening for prostate cancer is a matter of debate. Level 1 evidence from randomised controlled trials suggests a reduction in cancer-specific mortality from PCa screening. However, there could be an associated impact on quality of life due to a high proportion of overdiagnosis and overtreatment as part of the screening. The US Preventive Services Task Force (USPSTF) in 2012 recommended that PSA-based PCa screening should not to be offered at any age. However, considering the current evidence, USPSTF recently revised its recommendation to offer the PSA test to men aged 55-69 years with shared decision-making, in line with earlier guidelines from the American Cancer Society and the American Urological Association. A shared decision making is necessary since the PSA test could potentially harm an individual. However, the literature suggests that clinicians often neglect a discussion on this issue before ordering the test. This narrative discusses the main controversies regarding PCa screening including the PSA threshold for biopsy, the concept of overdiagnosis and overtreatment, the practical difficulties of active surveillance, the current level 1 evidence on the mortality benefit of screening, and the associated pitfalls. It offers a detailed discussion on the ethics involved in the PSA test and highlights the barriers to shared decision-making and possible solutions.

Determinants of Clinic Absenteeism: A Novel Method of Examining Distance from Clinic and Transportation

Delayed treatment and non-adherence are associated with inferior prostate cancer (CaP) outcomes. Missed clinic appointments (MA) are one form of non-adherence that may be preventable. We conducted a retrospective cohort study of 1341 scheduled clinic encounters for men referred to an academic urology clinic for evaluation of known or suspected CaP. Driving distance and public transit times were calculated using a Google Distance Matrix API algorithm. Zip code level data regarding socioeconomic status was obtained from the 2013 American Community Survey. Logistic regression multivariate analysis was used to identify MA predictors. Of scheduled clinic encounters, 14% were missed. Public health insurance was associated with MA (Private insurance 10%, Public insurance 19%), (p < 0.01) Calendar month was associated with MA with December showing the highest rate (21.2%) and June the lowest (5.3%) rates. (p = 0.02) Appointments for suspected CaP were more likely to be missed (19.3%) than those for known CaP (10.5%), p < 0.01. Driving distance was inversely associated with rate of MA (CA median 11.8 miles, MA median 10.4 miles, p = 0.04) while public transit times were not (66.7 min for CA, 65.3 min for MA, p = 0.36). Men that missed appointments were from areas with lower household incomes and educational attainment. Patient encounter type, insurance status, and reason for referral remained significantly associated with MA after multivariable adjusted analysis. By computing public transit time to the clinic using a mapping engine, we present a novel way to measure this parameter for studies of urban health care.