PHILADELPHIA — In general, clinical guidelines recommend conservative management, either active surveillance or watchful waiting, for men with low-risk and intermediate-risk prostate cancer. Use of conservative management is controversial, however, for African American patients, who have worse prostate cancer outcomes compared with white patients.
A study published in JAMA Network Open evaluated the association of African American race with the receipt and duration of conservative management at the VA, a large equal-access health system.
For the cohort study, Corporal Michael J. Crescenz VAMC-led researchers 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 Jan. 1, 2004, and Dec. 31, 2013, with analysis from Feb. 1 to June 30, 2020.
All patients received either definitive therapy—prostatectomy, radiation, androgen deprivation therapy—or conservative management—active surveillance or watchful waiting—according to the study. The focus was on patients who received conservative management and, for that group, time from diagnosis to definitive therapy. Participants were a median age of 65 (61-70) years, and 28.8% were African American veterans.
Results indicated that, compared with white veterans, African American veterans were more likely to have intermediate-risk disease (18 988 [51.7%] vs. 8526 [57.5%]), three 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%]).
Researchers pointed out that, overall, 20,606 veterans (40.0%) received conservative management. Yet, they added, African American veterans with low-risk disease (adjusted relative risk, 0.95; 95% CI, 0.92-0.98; P < 0.001) and intermediate-risk disease (adjusted relative risk, 0.92; 95% CI, 0.87-0.97; P = 0.002) were less likely to receive conservative management than white veterans.
Specifically, compared with white veterans, African American veterans with low-risk disease (adjusted hazard ratio, 1.71; 95% CI, 1.50-1.95; P < 0.001) and intermediate-risk disease (adjusted hazard ratio, 1.46; 95% CI, 1.27-1.69; P < 0.001) who received conservative management were more likely to receive definitive therapy within five years of diagnosis (restricted mean survival time [SE] at five years, 1679 [5.3] days vs. 1740 [2.4] days; P < 0.001).
“In this study, conservative management was less commonly used and less durable for African American veterans than for white veterans,” the authors concluded. “Prospective trials should assess the comparative effectiveness of conservative management in African American men with prostate cancer.”
- Parikh RB, Robinson KW, Chhatre S, Medvedeva E, Comparison by Race of Conservative Management for Low-Risk and Intermediate-Risk Prostate Cancers in Veterans From 2004 to 2018. JAMA Netw Open. 2020 Sep 1;3(9):e2018318. doi: 10.1001/jamanetworkopen.2020.18318. PMID: 32986109; PMCID: PMC7522702.