African American Men With Very Low–Risk Prostate Cancer Exhibit Adverse Oncologic Outcomes After Radical Prostatectomy: Should Active Surveillance Still Be an Option for Them?

Abstract

A B S T R A C T PurposeActive surveillance (AS) is a treatment option for men with very low-risk prostate cancer (PCa); however, favorable outcomes achieved for men in AS are based on cohorts that under-represent African American (AA) men. To explore whether race-based health disparities exist among men with very low-risk PCa, we evaluated oncologic outcomes of AA men with very low-risk PCa who were candidates for AS but elected to undergo radical prostatectomy (RP). Patients and MethodsWe studied 1,801 men (256 AA, 1,473 white men, and 72 others) who met National Comprehensive Cancer Network criteria for very low-risk PCa and underwent RP. Presenting characteristics, pathologic data, and cancer recurrence were compared among the groups. Multivariable modeling was performed to assess the association of race with upgrading and adverse pathologic features. ResultsAA men with very low-risk PCa had more adverse pathologic features at RP and poorer oncologic outcomes. AA men were more likely to experience disease upgrading at prostatectomy (27.3% v 14.4%; P Ͻ .001), positive surgical margins (9.8% v 5.9%; P ϭ .02), and higher Cancer of the Prostate Risk Assessment Post-Surgical scoring system (CAPRA-S) scores. On multivariable analysis, AA race was an independent predictor of adverse pathologic features (odds ratio, [OR], 3.23; P ϭ .03) and pathologic upgrading (OR, 2.26; P ϭ .03). ConclusionAA men with very low-risk PCa who meet criteria for AS but undergo immediate surgery experience significantly higher rates of upgrading and adverse pathology than do white men and men of other races. AA men with very low-risk PCa should be counseled about increased oncologic risk when deciding among their disease management options.

Racial Variation in Prostate Cancer Upgrading and Upstaging Among Men with Low-risk Clinical Characteristics

“…A recent Johns Hopkins study [7] compared AA and Caucasian men diagnosed with very low-risk PCa who underwent immediate RP and found that AA race was strongly and independently associated with upgrade and upstage after surgery. While these findings were notable because favorable outcomes had been expected among such a low-risk group, the cohort was from a single academic institution, which may limit the generalizability of the results.…”

“…However, despite improvements in clinical and pathologic assessment, there are considerable levels of upgrading and upstaging between biopsy and radical prostatectomy (RP). Upgrading and upstaging are well described in men otherwise eligible for AS who undergo surgery instead as primary treatment [6,7]. Depending on the criteria for defining AS eligibility, upgrading occurs in 23-35% of cases.…”

“…A 2013 study [7] compared AA and Caucasian men diagnosed with very low-risk disease who were candidates for AS but elected to undergo immediate RP. This study found a significantly lower rate of organ-confined cancers, higher rate of Gleason upgrading, and higher average postoperative risk score in AA men.…”

Prostate cancer in the African-Caribbean community

“…It is also somewhat contradictory given the higher rates of pathological upgrading after radical prostatectomy in African-American men with low-risk disease. 29 Moreover, adverse oncologic outcomes and lower biochemical recurrence-free survival are also reported after radical prostatectomy in African-American men. 30 Despite persistent efforts to tackle these issues, there are still significant mortality differences in prostate cancer among ethnic groups.…”

Novel Nomogram That Predicts Aggressive Disease and Treatment Failure Among African-American Men with Prostate Cancer

“…The genetic contribution to PCa disparity has been well established with the identification of significant racial differences in frequency and expression of various genes and biomarkers. Recently, several biomarkers (Table 1) have been shown to correlate with aggressive phenotypes in prostate cancer [15][16][17][18][19][20][21][22] . The most notable examples include the TMPRSS2:ERG gene fusion 23 , Ki-67 expression 17 , and biomarkers involved in androgen metabolism 8,18 .…”