Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan.
VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.
Cancer. 2021 Jul 1;127(13):2311-2318. doi: 10.1002/cncr.33485. Epub 2021 Mar 25.
Treatments for metastatic castration-resistant prostate cancer (CRPC) differ in toxicity, administration, and evidence. In this study, clinical and nonclinical factors associated with the first-line treatment for CRPC in a national delivery system were evaluated.
National electronic laboratory and clinical data from the Veterans Health Administration were used to identify patients with CRPC (ie, rising prostate-specific antigen [PSA] on androgen deprivation) who received abiraterone, enzalutamide, docetaxel, or ketoconazole from 2010 through 2017. It was determined whether clinical (eg, PSA) and nonclinical factors (eg, race, facility) were associated with the first-line treatment selection using multilevel, multinomial logistic regression. The average marginal effects (AMEs) were calculated of patient, disease, and facility characteristics on ketoconazole versus more appropriate CRPC therapy.
There were 4998 patients identified with CRPC who received first-line ketoconazole, docetaxel, abiraterone, or enzalutamide. After adjustment, increasing age was associated with receipt of abiraterone (adjusted odds ratio [aOR], 1.07; 95% credible interval [CrI], 1.06-1.09) or enzalutamide (aOR, 1.10; 95% CrI, 1.08-1.11) versus docetaxel. Greater preexisting comorbidity was associated with enzalutamide versus abiraterone (aOR, 1.53; 95% CrI, 1.23-1.91). Patients with higher PSA values at the start of treatment were more likely to receive docetaxel than oral agents and less likely to receive ketoconazole than other oral agents. African American men were more likely to receive ketoconazole than abiraterone, enzalutamide, or docetaxel (AME, 2.8%; 95% CI, 0.7%-4.9%). This effect was attenuated when adjusting for facility characteristics (AME, 1.9%; 95% CI, -0.4% to 4.1%).
Clinical factors had an expected effect on the first-line treatment selection. Race may be associated with the receipt of a guideline-discordant first-line treatment.
转移性去势抵抗性前列腺癌（CRPC）的治疗方法在毒性、给药方式和证据方面存在差异。在这项研究中，评估了与全国医疗体系中 CRPC 一线治疗相关的临床和非临床因素。
利用退伍军人健康管理局的全国电子实验室和临床数据，确定了 2010 年至 2017 年期间接受阿比特龙、恩扎卢胺、多西他赛或酮康唑治疗的 CRPC（即雄激素剥夺后 PSA 升高）患者。使用多层次多项逻辑回归确定临床（例如 PSA）和非临床因素（例如种族、医疗机构）与一线治疗选择是否相关。计算了患者、疾病和医疗机构特征对酮康唑与更合适的 CRPC 治疗的平均边际效应（AME）。
共确定了 4998 例接受一线酮康唑、多西他赛、阿比特龙或恩扎卢胺治疗的 CRPC 患者。调整后，年龄增长与接受阿比特龙（调整后的优势比 [aOR]，1.07；95%可信区间 [CrI]，1.06-1.09）或恩扎卢胺（aOR，1.10；95% CrI，1.08-1.11）治疗相关，而与多西他赛治疗相关。较高的预先存在的合并症与接受恩扎卢胺治疗而不是阿比特龙治疗相关（aOR，1.53；95% CrI，1.23-1.91）。治疗开始时 PSA 值较高的患者更有可能接受多西他赛治疗，而不是口服药物治疗，且不太可能接受酮康唑治疗，而不是其他口服药物治疗。非裔美国人男性更有可能接受酮康唑治疗，而不是阿比特龙、恩扎卢胺或多西他赛治疗（AME，2.8%；95%CI，0.7%-4.9%）。当调整医疗机构特征时，这种影响减弱（AME，1.9%；95%CI，-0.4%至 4.1%）。
临床因素对一线治疗选择有预期的影响。种族可能与接受不符合指南的一线治疗有关。
