Trends And Disparities In The Diagnosis And Initial Management Of High-Risk Prostate Cancer In The United States

Abstract

An increasing proportion of men are being diagnosed with high-risk prostate cancer. Standard of care for initial treatment of high-risk prostate cancer includes prostatectomy or radiotherapy with no randomized evidence comparing the modalities to guide decision-making. This study characterized US national trends associated with undergoing prostatectomy or radiotherapy for high-risk prostate cancer. This retrospective cohort study used data collected by the National Cancer Database (NCDB) to assess demographic, clinical and socioeconomic factors among 215,313 men diagnosed with high-risk prostate cancer from 2004 to 2016 and the trends in diagnosis rate and the use of prostatectomy or radiotherapy. Cochran-Armitage test was used to identify trends in prostatectomy or radiotherapy with time. Multivariable logistic regression was used to examine demographic and clinical factors associated with undergoing prostatectomy or radiotherapy. All tests were 2-sided and considered significant at an α level of .05. The rate of high-risk prostate cancer increased from 11.9% in 2004 to 20.4% in 2016. In total, 215,313 men diagnosed as having localized high-risk prostate cancer between 2004 and 2016 were identified. White men composed 81.2% of this cohort, whereas black men composed 16.1%. Government-issued insurance was used by 59.2% of men. More than 81.7% of men had a Charlson-Deyo Comorbidity Index score of 0 (range, 0 to ≥3, with lower numbers indicating fewer comorbidities). The proportion of men who underwent prostatectomy (a total of 76,606 men) compared to radiation therapy, androgen deprivation (ADT) alone, or no treatment, increased from 23.1% in 2004 to 40.9% in 2016 (p < .0001). The proportion of men who underwent radiotherapy as the first treatment (a total of 104,783 men) decreased from 59.7% in 2004 to 43.3% in 2016 (p < .0001). Men treated at an academic center, living in an urban area, or possessing higher incomes and those who were younger, healthier, white, or were diagnosed as having lower grade prostate cancer had higher odds of undergoing prostatectomy. This study found that rates of high-risk prostate cancer diagnosis have increased from 11.9% in 2004 to 20.4% in 2016. Prostatectomy rates for the initial treatment of high-risk prostate cancer increased by 17.8% from 2004 to 2016 and radiotherapy rates decreased by 16.4% in the same study period. Demographic, clinical and socioeconomic factors of high-risk cancer diagnosis and undergoing prostatectomy included age, race, income, Charlson-Deyo Comorbidity Index score, clinical stage and grade of disease, facility type and location, and year of diagnosis. These results are hypothesis generating; further studies evaluating potential disparities in the initial diagnosis and management of localized high-risk prostate cancer are warranted.