Association of Sociodemographic and Health-Related Factors With Receipt of Nondefinitive Therapy Among Younger Men With High-Risk Prostate Cancer
Authors: Alexander F. Bagley, Mitchell S. Anscher, Seungtaek Choi, Steven J. Frank, Karen E. Hoffman, Deborah A. Kuban, Sean E. McGuire, Quynh-Nhu Nguyen, Brian Chapin, Ana Aparicio, Todd A. Pezzi, Grace L. Smith, Benjamin D. Smith, Kenneth Hess, Chad Tang
Journal: JAMA Network Open (2020)

<h3>Importance</h3> Multiple randomized clinical trials have shown that definitive therapy improves overall survival among patients with high-risk prostate cancer. However, many patients do not receive definitive therapy because of sociodemographic and health-related factors. <h3>Objective</h3> To identify factors associated with receipt of nondefinitive therapy (NDT) among patients aged 70 years and younger with high-risk prostate cancer. <h3>Design, Setting, and Participants</h3> This cohort study identified 72 036 patients aged 70 years and younger with high-risk prostate cancer and Charlson Comorbidity Index scores of 2 or less who were entered in the National Cancer Database between January 2004 and December 2014. Data analysis was conducted from November 2018 to December 2019. <h3>Exposure</h3> Receipt of NDT as an initial treatment approach. <h3>Main Outcomes and Measures</h3> Survival rates were compared based on receipt of definitive therapy or NDT, and sociodemographic and health-related factors were associated with the type of therapy received. Residual life expectancy was estimated from the National Center for Health Statistics to calculate person-years of life lost. <h3>Results</h3> A total of 72 036 men with a median (range) age of 63 (30-70) years, Charlson Comorbidity Index scores of 2 or less, and high-risk prostate cancer without regional lymph node or distant metastatic disease were analyzed. Among eligible patients, 5252 (7.3%) received NDT as an initial therapeutic strategy. On univariate and multivariate analyses, NDT was associated with worse overall survival (univariate analysis hazard ratio, 2.54; 95% CI, 2.40-2.69;<i>P</i> &lt; .001; multivariate analysis hazard ratio, 2.40; 95% CI, 2.26-2.56;<i>P</i> &lt; .001). Compared with patients with private insurance or managed care, those with no insurance, Medicaid, or Medicare were more likely to receive systemic therapy only (no insurance: odds ratio [OR], 3.34; 95% CI, 2.81-3.98;<i>P</i> &lt; .001; Medicaid: OR, 2.92; 95% CI, 2.48-3.43;<i>P</i> &lt; .001; Medicare: OR, 1.36; 95% CI, 1.20-1.53;<i>P</i> &lt; .001) or no treatment (no insurance: OR, 2.63; 95% CI, 2.24-3.08;<i>P</i> &lt; .001; Medicaid: OR, 1.71; 95% CI, 1.45-2.01;<i>P</i> &lt; .001; Medicare: OR, 1.14; 95% CI, 1.04-1.24;<i>P</i> = .004). Compared with white patients, black patients were more likely to receive systemic therapy only (OR, 1.93; 95% CI, 1.74-2.14;<i>P</i> &lt; .001) or no treatment (OR, 1.46; 95% CI, 1.32-1.61;<i>P</i> &lt; .001), and Hispanic patients were more likely to receive systemic therapy only (OR, 1.36; 95% CI, 1.13-1.64;<i>P</i> = .001) or no treatment (OR, 1.36; 95% CI, 1.14-1.60;<i>P</i> &lt; .001). Between 2004 and 2014, patients without insurance or enrolled in Medicaid had 1.83-fold greater person-years of life lost compared with patients with private insurance (area under the curve, 77 600 vs 42 300 person-years of life lost). <h3>Conclusions and Relevance</h3> In this study, receipt of NDT was associated with insurance status and race/ethnicity. While treatment decisions should be individualized for every patient, younger men with high-risk prostate cancer and minimal comorbidities should be encouraged to receive definitive local therapy regardless of other factors. These data suggest that significant barriers to life-extending treatment options for patients with prostate cancer remain.