Although definitive therapy improves overall survival of patients with high-risk prostate cancer (PCa), a subset of patients continues to receive nondefinitive therapies (NDT) and suffer poor outcomes due to barriers such as their race or having public insurance, new research suggests.
Using the National Cancer Database, investigators identified 72,036 high-risk PCa patients aged 70 years or younger who were candidates for prostatectomy, external beam radiation therapy, and/or brachytherapy with or without androgen deprivation therapy (ADT) because they had no regional lymph node involvement or distant metastases and had Charlson Comorbidity Index scores of 2 or less. Of these, 5252 (7.3%) received NDT as initial management.
In multivariate analyses, NDT was associated with a 2.4-fold higher likelihood of poor overall survival compared with definitive therapy, Chad Tang, MD, of The University of Texas MD Anderson Cancer Center in Houston, and colleagues reported in JAMA Network Open. Mortality risks tripled with use of systemic therapy alone and nearly doubled with no treatment (ie, active surveillance or watchful waiting).
Compared with patients who had private insurance or managed care, men with no insurance, Medicaid, or Medicare had a significant 3.3-, 2.9-, and 1.4-fold greater likelihood of receiving systemic therapy alone (ie, ADT or chemotherapy), respectively. They also had a significantly 2.6-, 1.7-, and 1.1-fold greater likelihood of receiving no treatment, respectively.
Patients receiving systemic therapy alone appeared to have more bulky disease (ie, T3 or T4) than patients receiving no treatment, according to the researchers.
Race was another significant barrier to definitive care. Compared with white men, black men were nearly twice as likely to receive systemic therapy alone and 46% more likely to receive no treatment. For Hispanic men, both of these risks increased by a significant 36%.
Men with Medicaid or no insurance had 83% more person-years of life lost compared with the privately insured (77,600 vs 42,300 person-years of life lost).
According to the investigators, nonelderly men with high-risk prostate cancer and minimal comorbidities should be encouraged to receive definitive local therapy regardless of other factors.
“While it may be justified to withhold definitive local therapy for selected patients with significant medical comorbidities, most patients in this analysis (ie, 98%) had a medical comorbidity score of 0 or 1 and life expectancies of 13.9 years or greater,” Dr Tang’s team stated. “While policies, including the Patient Protection and Affordable Care Act, expanded health care access in the United States, this finding suggests that significant barriers to life-extending treatment options for younger patients with high-risk prostate cancer remain.”
Bagley AF, Anscher MS, Choi S, et al. Association of sociodemographic and health-related factors with receipt of nondefinitive therapy among younger men with high-risk prostate cancer. JAMA Netw Open. 2020;3(3):e201255. doi: 10.1001/jamanetworkopen.2020.1255