Barriers Impact Receipt of Life-Extending Treatment in High-Risk Prostate Cancer for Younger Patients

March 23, 2020

Article

A significant percentage of younger men with high-risk prostate cancer who display minimal comorbidities continue to receive nondefinitive therapy (NDT), despite research that has demonstrated local therapy is more beneficial in this patient population, according to findings from a study published in <em>JAMA Oncology</em> show. A number of reasons for this have been identified, including  insurance status and race/ethnicity.

A significant percentage of younger men with high-risk prostate cancer who display minimal comorbidities continue to receive nondefinitive therapy (NDT), despite research that has demonstrated local therapy is more beneficial in this patient population, according to findings from a study published in JAMA Oncologyshow. A number of reasons for this have been identified, including  insurance status and race/ethnicity.

Overall, 72,036 men with high-risk prostate cancer were analyzed, with a median age of 63 (range, 30-70). Ninety-eight percent of patients had a Charlson Comorbidity Index score between 0 and 1 and the diagnosis of high-risk prostate cancer without regional lymph node or distant metastatic disease. Previous clinical trials have demonstrated that definitive therapy can improve survival among patients with high-risk disease, but many patients do not receive this therapy due to sociodemographic and health-related reasons.

In total, 5,252 patients (7.3%) received NDT as initial therapy. However, select sociodemographic received NDT at higher rates, including uninsured patients (21.7%), Medicaid patients (18.0%), African American patients (12.8%), Hispanic patients (11.4%), and patients treated in a community setting (11.5%).

For patients receiving systemic therapy only, 37.2% had stage T3 or T4 disease while 8.1% with stage T3 or T4 disease received no treatment.

At the median follow-up of 54.9 months, the overall survival (OS) rates were 91.3% for definitive therapy (95% CI, 91.1-91.6), 83.5% for no therapy (95% CI, 81.9-85.0), and 69.8% for systemic therapy alone (95% CI, 67.5-71.9). NDT was associated with worse OS (HR, 2.54; 95% CI, 2.40-2.69;P<.001), according to univariate analysis. In a multivariate analysis, which analyzed factors such as insurance status, age, race/ethnicity, income, and educational levels), NDT was significantly associated with a worse OS (HR, 2.40; 95% CI, 2.26-2.56; P<.001).

Among the NDT subgroup, patients receiving systemic therapy only (HR, 3.06; 95% CI, 2.83-3.31;P<.001) and those receiving no active initial treatment (HR, 1.85; 95% CI, 1.69-2.02; P<.001) were independently associated with worse OS as well.

The most significant sociodemographic factor associated with receiving NDT was the patient’s insurance status; for those with no private insurance, they were more likely to receive systemic therapy only (OR, 3.34; 95% CI, 2.81-3.98;P<.001), as well as those on Medicaid (OR, 2.92; 95% CI, 2.48-3.43; P<.001) and those on Medicare (OR, 1.36; 95% CI, 1.20-1.53; P<.001). These subgroups were also more likely to receive no treatment (no insurance: OR, 2.63; 95% CI, 2.24-3.08; P < .001; Medicaid: OR, 1.71; 95% CI, 1.45-2.01;P < .001; Medicare: OR, 1.14; 95% CI, 1.04-1.24;P = .004).

Race/ethnicity, median household income level in the patient’s county of residence and treatment facility type were among other sociodemographic factors that were associated with receiving NDT. African Americans were more likely to receive systemic therapy only compared with Caucasians (OR, 1.93; 95% CI, 1.74-2.14;P<.001) or were more likely to receive no treatment (OR, 1.46; 95% CI, 1.32-1.61; P<.001). Hispanic patients were also more likely to received systemic therapy (OR, 1.36; 95% CI, 1.13-1.64; P<.001) or no treatment (OR, 1.36; 95% CI, 1.14-1.60; P<.001) compared with Caucasian patients.

Patients residing in counties with lower median household incomes of <$38,000 annually were more likely to receive systemic therapy only compared with those in counties with a median income of at least $63,000 annually (OR, 1.70; 95% CI, 1.49-1.95;P<.001). Patients who are treated in community cancer center programs were also more likely to received systemic therapy only compared with those treated at an academic or research facility (OR, 1.29; 95% CI, 1.13-1.48; P<.001).

African American and Hispanic patients who are uninsured received NDT at rates of 23.9% and 23.7%, respectively, compared with 16.9% of Caucasian patients who are uninsured. Investigators also noted considerable heterogeneity in treatment patterns among patients treated at individual treatment facilities and the number of patients treated per facility.

Patients without insurance or those with Medicaid had a 1.83-fold greater person-years of life lost (PYLL) compared with patients with private insurance between 2004 and 2014. PYLL is the product of the number of deaths within a given age or subgroup and the residual life expectancy in the absence of cancer.

Among patients under the age of 70 years, PYLL was greater in those without insurance or with Medicare compared to those with private insurance; the biggest difference was observed in patients aged 51 to 55 years, with a 2.14-fold greater PYLL in those with no insurance or Medicaid versus private insurance.

Both tumor stage and Charleson Comorbidity Index scores were independently associated with increased rates of NDT, the investigators noted. Patients with tumor stages T2, T3, and T4 were more likely to receive systemic therapy only (OR, 1.36; 95% CI, 1.22-1.51;P<.001) compared with those with tumor stage T1 (OR, 1.39; 95% CI, 1.24-1.57; P<.001). Patients with a Charleson Comorbidity Index score of 2 were more likely to receive systemic therapy only compared with those with a score of 0 (OR, 1,59; 95% CI, 1.24-2.02; P<.001).

This analysis, conducted at the University of Texas MD Anderson Cancer Center, identified patients from January 2004 to December 2014 who entered in the National Cancer Database with a diagnosis of high-risk prostate cancer. Several sociodemographic and disease-related variables were determined by investigators for analysis, including insurance status, income level, race/ethnicity, age, education level, great circle distance between residence and hospital, facility type, urban/rural group, clinical TNM stage, tumor histology, PSA level, Gleason score, and Charlson Comorbidity Index score.

To be included in the study, patients had to be 70 years or younger with a Charlson Comorbidity Index score of 2 or less, clinical NO (or NX) and MO disease, and adenocarcinoma histology. Patients were excluded if they received nononcologic local tumor excision or ablative procedures, such as cryoablation.

Reference:

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 [Published Online March 19, 2020].Jama Oncology. doi:10.1001/jamanetworkopen.2020.1255.