H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida.
Department of Veteran Affairs Salt Lake City Health Care System, Salt Lake City, Utah.
JAMA Netw Open. 2022 Jan 4;5(1):e2144027. doi: 10.1001/jamanetworkopen.2021.44027.
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.
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.
Self-identified African American (or Black) and White race and ethnicity.
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.
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).
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.
前列腺癌（PCa）在非裔美国男性中不成比例地高发，但在全国范围内，评估在同等医疗条件下 PCa 连续体中存在的种族和民族差异的研究仍然有限。美国退伍军人事务部（VA）退伍军人医院管理局的医疗保健系统提供了一个相对公平获得医疗服务的环境，可以在其中评估自我认定的非裔美国（或黑人）退伍军人和白人退伍军人中存在的种族和民族差异。
确定在 VA 医院接受诊断或治疗的非裔美国患者和白人患者中，PCa 的发病率、临床分期和结局方面存在的种族和民族差异的程度。
设计、地点和参与者：这项回顾性队列研究包括 7889984 名在全国范围内 VA 医院接受常规护理的退伍军人，时间范围为 2005 年至 2019 年（发病率队列）。估计了局部和新发转移性 PCa 的年龄调整发病率。评估了治疗反应，并比较了非裔美国退伍军人和白人退伍军人的 PCa 特异性结局。估计了 PCa 结局的残余差异，定义为尽管治疗反应相同，但在结局方面仍然存在的种族和民族差异。
自我认定的非裔美国（或黑人）和白人种族和族裔。
PCa 诊断后远处转移的时间是主要结局。使用描述性分析比较了基线人口统计学和临床特征。使用多变量逻辑回归评估了种族和族裔与治疗前临床变量的关联。使用多变量 Cox 回归估计转移风险。
从发病率队列中使用 7889984 名退伍军人的数据来估计发病率，而从 92269 名患有局限性 PCa 的退伍军人的数据来评估治疗反应。在 92269 名退伍军人中，与白人男性（n=63467；69%）相比，非裔美国男性（n=28802；31%）更年轻（中位数[IQR]，63[58-68] vs 65[62-71]岁），且在诊断时前列腺特异性抗原水平更高（>20ng/ml）。与美国人群水平数据一致，在全国范围内的 VA 中心，非裔美国退伍军人的局限性和新发转移性 PCa 的发病率几乎是非裔美国退伍军人的两倍。在接受 PCa 筛查的退伍军人中，与白人男性相比，非裔美国男性在前列腺活检中检测到 PCa 的风险增加了 29%（风险比，1.29；95%CI，1.27-1.31；P<0.001）。接受 PCa 确定性主要治疗的非裔美国男性发生转移的风险较低（风险比，0.89；95%CI，0.83-0.95；P<0.001）。然而，接受“其他”非确定性治疗的非裔美国男性更有可能发生转移（调整后的风险比，1.29；95%CI，1.17-1.42；P<0.001）。使用接受确定性主要治疗的退伍军人的实际转移率，观察到非裔美国男性在所有国家综合癌症网络风险组中（低危组，4 比每 100000 人 2 人；中危组，13 比每 100000 人 6 人；高危组，19 比每 100000 人 9 人）存在持续的转移性负担。
这项队列分析发现，非裔美国退伍军人和白人退伍军人之间在局部和转移性 PCa 的发病率方面存在显著差异。这种发病率的增加是导致在 VA 医院治疗的非裔美国退伍军人与白人退伍军人相比，尽管他们对治疗的反应几乎相同，但仍存在转移性 PCa 残余差异的主要因素。
