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. 2022 Jan 4;5(1):e2144027.
doi: 10.1001/jamanetworkopen.2021.44027.

Racial and Ethnic Disparities in Prostate Cancer Outcomes in the Veterans Affairs Health Care System

Affiliations

Racial and Ethnic Disparities in Prostate Cancer Outcomes in the Veterans Affairs Health Care System

Kosj Yamoah et al. JAMA Netw Open. .

Erratum in

  • Errors in Abstract and Results.
    [No authors listed] [No authors listed] JAMA Netw Open. 2022 Feb 1;5(2):e222773. doi: 10.1001/jamanetworkopen.2022.2773. JAMA Netw Open. 2022. PMID: 35188559 Free PMC article. No abstract available.

Abstract

Importance: Prostate cancer (PCa) disproportionately affects African American men, but research evaluating the extent of racial and ethnic disparities across the PCa continuum in equal-access settings remains limited at the national level. The US Department of Veterans Affairs (VA) Veterans Hospital Administration health care system offers a setting of relatively equal access to care in which to assess racial and ethnic disparities in self-identified African American (or Black) veterans and White veterans.

Objective: To determine the extent of racial and ethnic disparities in the incidence of PCa, clinical stage, and outcomes between African American patients and White patients who received a diagnosis or were treated at a VA hospital.

Design, setting, and participants: This retrospective cohort study included 7 889 984 veterans undergoing routine care in VA hospitals nationwide from 2005 through 2019 (incidence cohort). The age-adjusted incidence of localized and de novo metastatic PCa was estimated. Treatment response was evaluated, and PCa-specific outcomes were compared between African American veterans and White veterans. Residual disparity in PCa outcome, defined as the leftover racial and ethnic disparity in the outcomes despite equal response to treatment, was estimated.

Exposures: Self-identified African American (or Black) and White race and ethnicity.

Main outcomes and measures: Time to distant metastasis following PCa diagnosis was the primary outcome. Descriptive analyses were used to compare baseline demographics and clinic characteristics. Multivariable logistic regression was used to evaluate race and ethnicity association with pretreatment clinical variables. Multivariable Cox regression was used to estimate the risk of metastasis.

Results: Data from 7 889 984 veterans from the incidence cohort were used to estimate incidence, whereas data from 92 269 veterans with localized PCa were used to assess treatment response. Among 92 269 veterans, African American men (n = 28 802 [31%]) were younger (median [IQR], 63 [58-68] vs 65 [62-71] years) and had higher prostate-specific antigen levels (>20 ng/mL) at the time of diagnosis compared with White men (n = 63 467; [69%]). Consistent with US population-level data, African American veterans displayed a nearly 2-fold greater incidence of localized and de novo metastatic PCa compared with White men across VA centers nationwide. Among veterans screened for PCa, African American men had a 29% increased risk of PCa detection on a diagnostic prostate biopsy compared with White (hazard ratio, 1.29; 95% CI, 1.27-1.31; P < .001). African American men who received definitive primary treatment of PCa experienced a lower risk of metastasis (hazard ratio, 0.89; 95% CI, 0.83-0.95; P < .001). However, African American men who received nondefinitive treatment classified as “other” were more likely to develop metastasis (adjusted hazard ratio, 1.29; 95% CI, 1.17-1.42; P < .001). Using the actual rate of metastasis from veterans who received definitive primary treatment, a persistent residual metastatic burden for African American men was observed across all National Comprehensive Cancer Network risk groups (low risk, 4 vs 2 per 100 000; intermediate risk, 13 vs 6 per 100 000; high risk, 19 vs 9 per 100 000).

Conclusions and relevance: This cohort analysis found significant disparities in the incidence of localized and metastatic PCa between African American veterans and White veterans. This increased incidence is a major factor associated with the residual disparity in PCa metastasis observed in African American veterans compared with White veterans despite their nearly equal response to treatment.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Yamoah reported being an advisor for Flatiron Inc and Janssen R&D outside the submitted work. Dr Anglin-Foote reported being a federal employee at the Veterans Affairs medical center in Salt Lake City, Utah. Dr DuVall reported grants from Astellas Pharma, AstraZeneca Pharmaceuticals LP, Boehringer Ingelheim International GmbH, Celgene Corporation, Eli Lilly and Company, Genentech Inc, Genomic Health Inc, Gilead Sciences Inc, GlaxoSmithKline PLC, Innocrin Pharmaceuticals Inc, Janssen Pharmaceuticals Inc, Kantar Health, Myriad Genetic Inc, Novartis International AG, and Parexel International Corporation outside the submitted work. Dr Wong reported grants from the Prostate Cancer Foundation during the conduct of the study; and employment by Johnson & Johnson (Janssen) outside the submitted work. Dr Nickols reported grants from Bayer, Janssen, and Lantheus; and personal fees from Oncolinea outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Flow Diagram
PCa indicates prostate cancer.
Figure 2.
Figure 2.. Incidence of Prostate Cancer and De Novo Metastasis at Diagnosis Across Veterans Affairs Centers
C, Incidence-level racial and ethnic disparities across the US shown by state. Veteran Affairs–based racial and ethnic disparities in the incidence of prostate cancer (D) and de novo metastasis (E). Incidence rates are reported per 100 000 men.
Figure 3.
Figure 3.. Time to Prostate Cancer (PCa) Diagnostic Biopsy Based on Screening Prostate-Specific Antigen (PSA) Level Among African American Veterans and Cumulative Incidence of PCa Diagnostic Biopsy
A, Reference is White men. HR indicates hazard ratio.
Figure 4.
Figure 4.. Residual Metastatic Burden Between African American and White Veterans Across National Comprehensive Cancer Network Risk Groups After Definitive Treatment
Prostate cancer incidence rates across National Comprehensive Cancer Network risk groups are not age adjusted. aTen-year metastatic rates are derived by dividing the total number of metastatic events by the number of at-risk patients who received definitive primary treatment (n = 56 083).

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