Active Surveillance for Low-Risk Prostate Cancer in Black Patients
Authors: Butler S, Muralidhar V, Chavez J, Fullerton Z, Mahal A, Nezolosky M, Vastola M, Zhao SG, D’Amico AV, Dess RT, Feng FY, King MT, Mouw KW, Spratt DE, Trinh Q-D, Nguyen PL, Rebbeck TR, Mahal BA
Conservative management (active surveillance or watchful waiting) for low-risk prostate cancer is an increasingly used alternative to definitive radiation therapy or radical prostatectomy.1,2 Given the underrepresentation of black patients in clinical trials and concern about underlying aggressive disease,3,4 expert panels advise caution when applying conservative management to black patients.1 Therefore, we examined recent trends in the use of active surveillance or watchful waiting in black men, as compared with nonblack men, with low-risk prostate cancer in the United States.
The Surveillance, Epidemiology, and End Results Prostate with Watchful Waiting Database identified patients with low-risk prostate cancer (defined as a clinical stage of T1 to T2a [indicating early-stage disease], a Gleason score of ≤6 [on a scale from 2 to 10, with scores of ≤6 indicating low-risk cancer], and a prostate-specific antigen level of less than 10 ng per milliliter) for which the management type was known and that had been diagnosed between 2010 and 2015.5 Additional details about this cohort and the study design are provided in the Supplementary Appendix, available with the full text of this letter at NEJM.org.
We used the Cochran–Armitage test to evaluate trends in initial management over time. Multivariable logistic regression was used to define adjusted odds ratios and 95% confidence intervals for the receipt of active surveillance or watchful waiting as compared with definitive treatment, with race as the primary independent variable. We used the validated Yost index to adjust for socioeconomic status.5 Information regarding all the variables that were included in the models is provided in the Supplementary Appendix...