Prostate Cancer: Comparing Active Surveillance for Blacks vs Whites

by Leah Lawrence, Contributing Writer, MedPage TodayTwo outcomes worse, but reassurance from two other key results, VA study shows.

Black men with low-risk prostate cancer undergoing active surveillance had a significantly increased incidence of disease progression and a higher likelihood of needing definitive treatment compared with white men, but did not have an increased incidence of metastasis or prostate-cancer specific mortality, according to a study of men in the Veterans Health Administration (VHA) system.

A computer rendering of a test tube of blood labeled PSA TEST in front of a prostate and EKGThe retrospective study of 8,726 men in the VHA, including 2,280 Black men, followed for a median 7.6 years showed similar rates of prostate cancer-specific mortality (1.1% vs 1.0%) for Black vs white men despite a more than 10% difference in 10-year cumulative incidence of disease progression (59.9% vs 48.3%; P<0.001) and receipt of definitive treatment (54.8% vs 41.4%; P<0.001), reported Brent S. Rose, MD, of University of California San Diego Health, Moores Cancer Cancer, and colleagues.

In the new study, multivariable analysis showed that Black men with prostate cancer were about 30% more likely to have disease progression (subdistribution hazard ratio [SHR] 1.3, 95% CI 1.2-1.4, P<0.001) and receive definitive treatment (SHR 1.3, 95% CI 1.2-1.4, P<0.001) compared with white men.

Despite this increased risk, however, the rates of metastatic disease were similar between the two groups: cumulative incidence at 10 years of 1.5% for Black men and 1.4% for white men.

Additionally, prostate-cancer specific and all-cause mortality rates were similar between the two patient populations, with Black men having no increased risk on multivariable competing risk regression analyses, the researchers reported.

“Hopefully, these results encourage African American men with low-risk prostate cancer to consider active surveillance,” Rose told MedPage Today. “Additionally, these findings may support higher rates of PSA screening and early detection if men know that they may not need treatment if they find a low-risk cancer. This will help us to identify the aggressive cancers that do need to be treated in order to reduce the disparity in prostate cancer outcomes for African American men.”

Writing in an accompanying editorial, Xinglei Shen, MD, MS, of the University of Kansas Medical Center in Kansas City, and colleagues acknowledged the dearth of data about whether active surveillance — the use of which is increasing, they note — is as safe for Black prostate cancer patients as it is for white men with the disease.

Because Black patients have more biologically aggressive prostate cancer and higher progression rates during active surveillance compared with white men, there is a greater need for Black men in the general population to have access to high-quality and timely care to avoid delays in diagnosing cancer progression and receiving definitive treatment, the editorialists emphasized.

Indeed, Rose said, it will be important that Black men who decide to undergo active surveillance receive the frequent PSA testing, repeat biopsies, and in some cases imaging that is required.

Additionally, Shen and colleagues wrote, how well active surveillance is being implemented into routine practice — for all men — has not been well studied. In the study by Rose and colleagues, all men had undergone at least one surveillance biopsy and had a median of 12 prostate-specific antigen (PSA) tests. In contrast, a study reported at the 2019 American Society of Clinical Oncology annual meeting using data from a North Carolina cancer registry showed that only 58% of patients received routine surveillance PSA tests within the first 2 years of surveillance, and only 45% had a surveillance biopsy.

“Further reassurance [about active surveillance] would be gained from research showing similar outcomes in broader general population settings outside of the VHA context,” Shen and co-authors concluded. “Until such evidence is available, concerns about biologic differences in prostate cancer between Black and White men and potential disparities in receiving timely surveillance monitoring and treatment on cancer progression may continue to drive lower rates of active surveillance use among Black patients.”

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