Prostate Cancer and Prostatic Diseases最新文献

Background

Previous studies have shown that Black men receive worse prostate cancer care than White men. This has not been explored in metastatic castration-sensitive prostate cancer (mCSPC) in the current treatment era.

Methods

We evaluated treatment intensification (TI) and overall survival (OS) in Medicare (2015–2018) and Veterans Health Administration (VHA; 2015–2019) patients with mCSPC, classifying first-line mCSPC treatment as androgen deprivation therapy (ADT) + novel hormonal therapy; ADT + docetaxel; ADT + first-generation nonsteroidal antiandrogen; or ADT alone.

Results

We analyzed 2226 Black and 16,071 White Medicare, and 1020 Black and 2364 White VHA patients. TI was significantly lower for Black vs White Medicare patients overall (adjusted odds ratio [OR] 0.68; 95% confidence interval [CI] 0.58–0.81) and without Medicaid (adjusted OR 0.70; 95% CI 0.57–0.87). Medicaid patients had less TI irrespective of race. OS was worse for Black vs White Medicare patients overall (adjusted hazard ratio [HR] 1.20; 95% CI 1.09–1.31) and without Medicaid (adjusted HR 1.13; 95% CI 1.01–1.27). OS was worse in Medicaid vs without Medicaid, with no significant OS difference between races. TI was significantly lower for Black vs White VHA patients (adjusted OR 0.75; 95% CI 0.61–0.92), with no significant OS difference between races.

Conclusions

Guideline-recommended TI was low for all patients with mCSPC, with less TI in Black patients in both Medicare and the VHA. Black race was associated with worse OS in Medicare but not the VHA. Medicaid patients had less TI and worse OS than those without Medicaid, suggesting poverty and race are associated with care and outcomes.

Background: Although active surveillance is the preferred management for low-risk prostate cancer (PCa), some men remain at risk of overtreatment with definitive local therapy. We hypothesized that baseline characteristics may be associated with overtreatment and represent a potential source of health disparities. We therefore examined the associations of patient and disease characteristics with the surgical overtreatment of low-risk PCa.

Methods: We identified men aged 45-75 years with cT1 cN0 cM0 prostate adenocarcinoma with biopsy Gleason score 6 and PSA < 10 ng/ml from 2010-2016 in the National Cancer Database (NCDB) and who underwent radical prostatectomy (RP). We evaluated the associations of baseline characteristics with clinically insignificant PCa (iPCa) at RP (i.e., "overtreatment"), defined as organ-confined (i.e., pT2) Gleason 3 + 3 disease, using multivariable logistic regression.

Results: We identified 36,088 men with low-risk PCa who underwent RP. The unadjusted rate of iPCa decreased during the study period, from 54.7% in 2010 to 40.0% in 2016. In multivariable analyses adjusting for baseline characteristics, older age (OR 0.98, 95% CI 0.97-0.98), later year of diagnosis (OR 0.62, 95% CI 0.57-0.67 for 2016 vs. 2010), Black race (OR 0.85, 95% CI 0.79-0.91), treatment at an academic/research program (OR 0.82, 95% CI 0.73-0.91), higher PSA (OR 0.91, 95% CI 0.90-0.92), and higher number of positive biopsy cores (OR 0.87, 95% CI 0.86-0.88) were independently associated with a lower risk of overtreatment (iPCa) at RP. Conversely, a greater number of biopsy cores sampled (OR 1.01, 95% CI 1.01-1.02) was independently associated with an increased risk of overtreatment (iPCa) at RP.

Conclusions: We observed an ~27% reduction in rates of overtreatment of men with low-risk PCa over the study period. Several patient, disease, and structural characteristics are associated with detection of iPCa at RP and can inform the management of men with low-risk PCa to reduce potential overtreatment.

Background: There are no large head-to-head phase 3 clinical trials comparing overall survival (OS) for abiraterone and enzalutamide. This study used Medicare claims data to compare OS in patients with chemotherapy-naïve metastatic castration-resistant prostate cancer (mCRPC) who initiated abiraterone or enzalutamide.

Methods: This retrospective analysis of the Medicare database (2009-2020) included adult men with ≥1 claim for prostate cancer, metastatic diagnosis, and no prior chemotherapy or novel hormone therapy who initiated first-line (1L) abiraterone or enzalutamide in the index period (September 10, 2014 to May 31, 2017). Cox proportional-hazards models with inverse probability treatment-weighting (IPTW) were used to compare OS between abiraterone- and enzalutamide-treated patients, adjusting for baseline characteristics. Subgroup analyses by baseline characteristics were also conducted.

Results: Overall, 5506 patients who received 1L abiraterone (n = 2911) or enzalutamide (n = 2595) were included. Median follow-up was comparable in both cohorts (abiraterone, 19.1 months; enzalutamide, 20.3 months). IPTW-adjusted median OS (95% CI) was 20.6 months (19.7‒21.4) for abiraterone and 22.5 months (21.2‒23.8) for enzalutamide, with an IPTW-adjusted hazard ratio (95% CI) of 1.10 (1.04-1.16). Median OS was significantly shorter for abiraterone versus enzalutamide in patients ≥75 years old; White patients; patients with baseline diabetes, cardiovascular disease, both diabetes and cardiovascular disease, and renal disease; and across all socioeconomic strata.

Conclusions: In the Medicare chemotherapy-naïve mCRPC population, 1L abiraterone was associated with worse OS versus enzalutamide in the overall population and among subgroups with older age and comorbidities, supporting findings from previous real-world studies and demonstrating a disparity in outcomes.

Background: This study supports a value-based approach to prostate cancer (PCa) treatment by systematically reviewing economic evaluations that compare the cost and cost-effectiveness of low-dose-rate brachytherapy (LDR-BT) with that of other treatment options for localised and locally advanced PCa.

Methods: Studies published between 2008 and 2023 were searched for in MEDLINE, EMBASE and Tufts Medical Center's Cost-Effectiveness Analysis (CEA) Registry (Prospero protocol CRD42023-442027). Two reviewers independently screened the title and abstracts based on agreed inclusion and exclusion criteria, followed by full-text screening. The Drummond checklist was used to critically appraise the quality of the included studies.

Results: After screening 453 records, 36 were sought for retrieval and 14 eligible studies included. Of them, 11 compared treatments for low- and/or favourable intermediate-risk PCa, 2 compared options for unfavourable intermediate- and/or high-risk disease and 1 analysed treatments for both risk groups. Considerable heterogeneity was seen in the populations, perspectives, time horizons, costs and outcomes data used. If the oncological outcomes of standard treatment approaches are considered equivalent, LDR-BT was the most cost-effective type of radiation therapy (RT) in 9 (75%) of 12 studies, was more cost-effective than radical prostatectomy (RP) in 6 (67%) of 9 studies and, depending on the time horizon, was more cost-effective than active surveillance (AS) in 3 (60%) of 5 studies. LDR-BT was more cost-effective than high-dose-rate brachytherapy (HDR-BT) in all 4 (100%) of the studies that made this comparison and, overall, LDR-BT was the least costly of all active treatment options in 7 (50%) of the 14 studies.

Conclusion: The available health economic evidence suggests that LDR-BT has significant cost advantages and an important role to play in the delivery of value-based PCa care. In the future these advantages could be challenged if radiotherapy favours ultrahypofractionated strategies such as stereotactic body radiation therapy (SBRT) and reduced fractionation in HDR-BT.