Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Department of Urology, University Hospital Frankfurt, Frankfurt am Main, Germany.
Prostate Cancer Prostatic Dis. 2019 Mar;22(1):125-136. doi: 10.1038/s41391-018-0083-4. Epub 2018 Aug 31.
Racial differences in prostate cancer (PCa) outcomes in the United States may be due to differences in tumor biology and race-based differences in access and treatment. We designed a study to estimate the relative contribution of these factors on Black/White disparities in overall survival (OS) in advanced PCa.
We identified Black and White men aged ≥ 40 years with metastatic or locally advanced PCa (cN+ cM+ and/or T3/4) between 2004 and 2010 using the National Cancer Database. We employed sequential propensity score weighting procedures to generate simulated cohorts of Black and White patients with equal demographics, access to care, treatment, and tumor characteristics. Adjusted survival analyses were used to compare survival in these simulated cohorts. The changes in relative survival after each weighting procedure were used to infer the contribution of each set of variables on the excess risk of mortality in Blacks.
In total, 35,611 men met inclusion criteria, 5927 (16.77%) of whom were Black. Survival was significantly worse for Black men after adjusting for demographics and comorbidities (hazard ratio (HR) 1.27, 95%-confidence interval (95%-CI) 1.2-1.34, p < 0.001). After simulating equal access to care, there was no significant difference in survival between races (HR 1.04, 95%-CI 0.97-1.12, p = 0.276), despite worse tumor characteristics in Blacks. After simulating equal treatment and equivalent tumor characteristics, Black men had a better survival than Whites (HR 0.93, 95%-CI 0.86-1.01, p = 0.071 and HR 0.92, 95%-CI 0.84-1.00, p = 0.043, respectively). Overall, access-related variables explained 84.7% of the excess risk of death in Black men.
Our analysis of men with advanced PCa revealed worse OS among Blacks. However, when access to care, treatment, and cancer characteristics are accounted for, Black race was associated with better OS. These findings suggest that initiatives to improve access to care may represent an effective tool to reduce disparities in PCa outcomes.
美国前列腺癌（PCa）结果的种族差异可能归因于肿瘤生物学的差异以及基于种族的获得和治疗差异。我们设计了一项研究，以估计这些因素对晚期 PCa 中黑人和白人之间总生存（OS）差异的相对贡献。
我们使用国家癌症数据库，确定了 2004 年至 2010 年间年龄≥40 岁的患有转移性或局部晚期 PCa（cN+ cM+和/或 T3/4）的黑人和白人男性。我们采用连续倾向评分加权程序，为黑人和白人患者生成具有相等人口统计学，获得护理，治疗和肿瘤特征的模拟队列。调整后的生存分析用于比较这些模拟队列中的生存情况。在每次加权程序后，生存变化用于推断每一组变量对黑人死亡率过高的风险的贡献。
共有 35611 名男性符合纳入标准，其中 5927 名（16.77%）为黑人。调整人口统计学和合并症后，黑人男性的生存明显较差（危险比（HR）1.27，95%置信区间（95%CI）1.2-1.34，p<0.001）。在模拟获得平等护理机会后，尽管黑人的肿瘤特征较差，但种族之间的生存没有差异（HR 1.04，95%CI 0.97-1.12，p=0.276）。在模拟平等治疗和等效肿瘤特征后，黑人男性的生存状况优于白人（HR 0.93，95%CI 0.86-1.01，p=0.071 和 HR 0.92，95%CI 0.84-1.00，p=0.043）。总体而言，与获得相关的变量解释了黑人男性死亡风险过高的 84.7%。
我们对患有晚期 PCa 的男性进行的分析显示，黑人的 OS 较差。然而，当考虑获得护理，治疗和癌症特征时，黑人种族与更好的 OS 相关。这些发现表明，改善获得护理的举措可能是减少 PCa 结果差异的有效工具。
