Abstract
Conservative management (ie, active surveillance or watchful waiting) is a guideline-based strategy for men with low-risk and intermediate-risk prostate cancer. However, use of conservative management is controversial for African American patients, who have worse prostate cancer outcomes compared with White patients. To examine the association of African American race with the receipt and duration of conservative management in the Veterans Health Administration (VA), a large equal-access health system. This cohort study used data from the VA Corporate Data Warehouse for 51 543 African American and non-Hispanic White veterans diagnosed with low-risk and intermediate-risk localized node-negative prostate cancer between January 1, 2004, and December 31, 2013. Men who did not receive continuous VA care were excluded. Data were analyzed from February 1 to June 30, 2020. All patients received either definitive therapy (ie, prostatectomy, radiation, androgen deprivation therapy) or conservative management (ie, active surveillance or watchful waiting). Receipt of conservative management and (for patients receiving conservative management) time from diagnosis to definitive therapy. The median (interquartile range) age of the 51 543 veterans in our cohort was 65 (61-70) years, and 14 830 veterans (28.8%) were African American individuals. Compared with White veterans, African American veterans were more likely to have intermediate-risk disease (18 988 [51.7%] vs 8526 [57.5%]), 3 or more comorbidities (15 438 [42.1%] vs 7614 [51.3%]), and high disability-related or income-related needs (9078 [24.7%] vs 4614 [31.1%]). Overall, 20 606 veterans (40.0%) received conservative management. African American veterans with low-risk disease (adjusted relative risk, 0.95; 95% CI, 0.92-0.98; P < .001) and intermediate-risk disease (adjusted relative risk, 0.92; 95% CI, 0.87-0.97; P = .002) were less likely to receive conservative management than White veterans. Compared with White veterans, African American veterans with low-risk disease (adjusted hazard ratio, 1.71; 95% CI, 1.50-1.95; P < .001) and intermediate-risk disease (adjusted hazard ratio, 1.46; 95% CI, 1.27-1.69; P < .001) who received conservative management were more likely to receive definitive therapy within 5 years of diagnosis (restricted mean survival time [SE] at 5 years, 1679 [5.3] days vs 1740 [2.4] days; P < .001). In this study, conservative management was less commonly used and less durable for African American veterans than for White veterans. Prospective trials should assess the comparative effectiveness of conservative management in African American men with prostate cancer.
Highlights
Conservative management of low-risk or intermediate-risk prostate cancer with active surveillance or watchful waiting is a guideline-based alternative to definitive prostatectomy or radiation.[1]
Compared with White veterans, African American veterans with low-risk disease and intermediate-risk disease who received conservative management were more likely to receive definitive therapy within 5 years of diagnosis
After adjusting for all covariates, African American veterans with low-risk and intermediate-risk prostate cancer had a lower likelihood of receiving conservative management than White veterans
Summary
Conservative management of low-risk or intermediate-risk prostate cancer with active surveillance or watchful waiting is a guideline-based alternative to definitive prostatectomy or radiation.[1]. This raises the possibility of race-based, biological differences in low-risk prostate cancer and has led to a debate regarding whether African American patients should be candidates for conservative management.[8,9,10] Understanding racial differences in the uptake and duration of conservative management is key to counseling African American men regarding the risks and benefits of conservative management
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