Race as an outcome predictor after radical prostatectomy: results from the Shared Equal Access Regional Cancer Hospital (SEARCH) database

doi:10.1016/S0090-4295(02)01847-2

Urology

Volume 60, Issue 4, October 2002, Pages 670-674

https://doi.org/10.1016/S0090-4295(02)01847-2 Get rights and content

Abstract

Objectives

Whether race is an independent predictor of prostate-specific antigen (PSA) recurrence after RP is controversial. To compare racial differences in clinical and pathologic features and biochemical recurrence in men undergoing radical prostatectomy (RP), we used a newly established multicenter database of patients from four equal-access healthcare centers in California, the Shared Equal Access Regional Cancer Hospital (SEARCH) database.

Methods

A retrospective survey of 1547 patients treated with RP at four different equal-access medical centers in California between 1988 and 2001 was undertaken. Race was categorized as white (n = 1014), black (n = 338), or nonwhite-nonblack (n = 195). Patients were analyzed for racial differences in preoperative variables (age at surgery, clinical stage, PSA, and biopsy Gleason score) and surgical variables (pathologic stage, surgical Gleason score, incidence of seminal vesicle invasion, positive surgical margins, capsular penetration, and pelvic lymph node involvement). Patients were followed up for PSA recurrence. Multivariate analysis was used to determine whether race was an independent predictor of biochemical failure.

Results

Significant differences were found among the races in the preoperative factors of clinical stage, age, serum PSA, and biopsy Gleason score, although the absolute differences were small. No differences were found among the races in the pathologic features of the RP specimens, including Gleason score, pathologic stage, and incidence of positive surgical margins, capsular penetration, seminal vesicle invasion, or lymph node involvement. In both univariate and multivariate analyses, only serum PSA (P <0.001) and biopsy Gleason score (P <0.001) were significant independent predictors of time to biochemical recurrence.

Conclusions

In a large multicenter cohort of patients from four equal-access medical care facilities in California, although racial differences were found in clinical stage, age, biopsy Gleason score, and serum PSA level at diagnosis, we found race was not an independent predictor of biochemical recurrence after RP. Race should not be used in models or nomograms predicting PSA failure after RP. The current study represents the largest series of black patients and the first large series of nonwhite-nonblack patients treated with RP reported to date. The Shared Equal Access Regional Cancer Hospital database is a valuable resource for studying patients treated with RP.

Section snippets

Material and methods

Data from consecutive patients undergoing RP at the West Los Angeles, Palo Alto, and San Francisco VAMCs and the San Diego Naval Medical Center were combined into the SEARCH database.

Patients treated with preoperative androgen deprivation or radiotherapy or found to have Stage T0 tumors on final pathologic examination were excluded. Sixty-three patients whose race was unknown were excluded. Nineteen patients who underwent RP before 1988 were excluded because only one of these patients had

Results

Table I demonstrates the clinical and pathologic characteristics of the study population. The black patients were younger and had higher serum PSA values than the white or nonwhite-nonblack patients. The nonwhite-nonblack patients had higher biopsy Gleason scores than the other groups. In addition, the white patients had a more advanced clinical stage than the other groups. No differences were found in the pathologic stage or grade, positive surgical margins, or incidence of capsular

Comment

Using the multicenter SEARCH database of patients treated with RP at four equal-access medical centers, we examined racial differences among clinical and pathologic variables and PSA recurrence. This is the largest series to date of black (n = 336) and nonwhite-nonblack (n = 192) men to examine racial differences among patients treated with RP. Although the differences in clinical stage, age, biopsy Gleason score, and serum PSA were significant, the differences in the pathologic findings among

Conclusions

Using the new SEARCH database of patients treated with RP at four equal-access medical centers, we found that although racial differences are present at diagnosis, race was not an independent predictor of pathologic findings or PSA recurrence after RP. Therefore, race should not be used in models or nomograms to predict disease recurrence after RP. The current study represents the largest series of black and the first large series of nonwhite-nonblack patients treated with RP reported to date.

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Cited by (96)

Pathological and Biochemical Outcomes among African-American and Caucasian Men with Low Risk Prostate Cancer in the SEARCH Database: Implications for Active Surveillance Candidacy
2016, Journal of Urology
Racial disparities in the incidence and risk profile of prostate cancer at diagnosis among African-American men are well reported. However, it remains unclear whether African-American race is independently associated with adverse outcomes in men with clinical low risk disease.
We retrospectively analyzed the records of 895 men in the SEARCH (Shared Equal Access Regional Cancer Hospital) database in whom clinical low risk prostate cancer was treated with radical prostatectomy. Associations of African-American and Caucasian race with pathological biochemical recurrence outcomes were examined using chi-square, logistic regression, log rank and Cox proportional hazards analyses.
We identified 355 African-American and 540 Caucasian men with low risk tumors in the SEARCH cohort who were followed a median of 6.3 years. Following adjustment for relevant covariates African-American race was not significantly associated with pathological upgrading (OR 1.33, p = 0.12), major upgrading (OR 0.58, p = 0.10), up-staging (OR 1.09, p = 0.73) or positive surgical margins (OR 1.04, p = 0.81). Five-year recurrence-free survival rates were 73.4% in African-American men and 78.4% in Caucasian men (log rank p = 0.18). In a Cox proportional hazards analysis model African-American race was not significantly associated with biochemical recurrence (HR 1.11, p = 0.52).
In a cohort of patients at clinical low risk who were treated with prostatectomy in an equal access health system with a high representation of African-American men we observed no significant differences in the rates of pathological upgrading, up-staging or biochemical recurrence. These data support continued use of active surveillance in African-American men. Upgrading and up-staging remain concerning possibilities for all men regardless of race.
Racial/ethnic differences in the relative risk of receipt of specific treatment among men with prostate cancer
2016, Urologic Oncology: Seminars and Original Investigations
Citation Excerpt :
Additionally, data from equal-access care hospitals demonstrate that when AA receive equivalent surgical and adjuvant care for stage-matched disease, survival outcomes are improved and are similar to their White counterparts [16]. This mirrors similar findings in the PCa literature that have shown that AA men who receive RP may experience similar biochemical recurrence-free survival despite worse presenting disease, and it underscores the importance of equal application of stage-appropriate standard treatment [17]. Breast cancer is another malignancy with a widening survival disparity between AA and White women, with data from the equal-access Department of Defense health care system suggesting that access to care may not be the only barrier to optimal outcomes [18].
African-American (AA) men have excess mortality from prostate cancer compared with White men, which has remained unchanged over several decades. The purpose of this study is to determine if race/ethnicity is an independent predictor of receipt of any definitive treatment vs. watchful waiting/active surveillance (WW/AS).
Men diagnosed with prostate cancer from 2004 to 2011 were identified from the Surveillance, Epidemiology, and End-Results program. Multinomial logistic regression analysis was performed to determine the relative risk ratio (RRR) of receipt of radical prostatectomy (RP), external beam radiation therapy (RT), brachytherapy, cryotherapy, or combination therapy vs. WW/AS.
Compared with White men, AA men were significantly less likely to receive RP (RRR = 0.53, P<0.001), brachytherapy (RRR = 0.72, P<0.001), cryotherapy (RRR = 0.84, P = 0.001), and combination therapy (RRR = 0.70, P<0.001), and more likely to receive RT (RRR = 1.03, P = 0.041) vs. AS/WW. Hispanic men were significantly less likely to receive RP (RRR = 0.84, P<0.001) and brachytherapy (RRR = 0.77, P<0.001), and more likely to receive RT (RRR = 1.08, P<0.001), and cryotherapy (RRR = 1.19, P = 0.005) vs. AS/WW compared with White men.
The disparate risk of receiving definitive treatment among AA and Hispanic men represents a significant public health issue that requires efforts to improve physician education, increase cultural competency, and ensure equitable access.
Race, Ethnicity, Marital Status, Literacy, and Prostate Cancer Outcomes in the United States
2016, Prostate Cancer: Science and Clinical Practice: Second Edition
There are persistent and consistent disparities in screening, treatment, and survival among African-American men, as well as Hispanic men to a lesser degree, compared to Caucasian men. Additionally, men with low socioeconomic status and men with inadequate social support experience adverse outcomes. Treatment disparities remain the most significant determinant of prostate cancer survival, but marital status, genetic abnormalities, and literacy/numeracy play a smaller, but important, role. In this chapter, we present the pertinent data describing the sources of disparity, and strategies to reduce or eliminate these differences.
Does larger tumor volume explain the higher prostate specific antigen levels in black men with prostate cancer-Results from the SEARCH database
2015, Cancer Epidemiology
Citation Excerpt :
Multiple previous population-based studies have demonstrated that black men have higher prostate-specific antigen (PSA) values than white men [1,2]. Similar results have been seen among men with prostate cancer [3] and specifically among men undergoing radical prostatectomy [4–6]. There are multiple potential explanations for a higher serum PSA including larger prostate size and larger tumor size [7].
To assess whether larger tumor volume in black men explains higher presurgical PSA levels versus white men with prostate cancer.
We retrospectively analyzed 1904 men from the Shared Equal Access Regional Cancer Hospital database who underwent radical prostatectomy from 1990 to 2013. Geometric mean of tumor volume and preoperative PSA for each race were estimated from multivariable linear regression models.
There were 1104 (58%) white men and 800 (42%) black men. Black men were younger (60.2 vs. 62.9 years, p < 0.001) had a higher PSA (6.7 vs. 6.0 ng/mL, p < 0.001), more positive margins (47 vs. 38%, p < 0.001), and seminal vesicle invasion (13 vs. 9%, p = 0.007). White patients had higher clinical stage (p < 0.001) and greater median tumor volume (6.0 vs. 5.3 gm, p = 0.011). After multivariable adjustment (except for PSA), white men had smaller mean tumor volumes (5.2 vs. 5.8 gm, p = 0.011). When further adjusted for PSA, there was no racial difference in mean tumor volume (p = 0.34). After multivariable adjustment, black men had higher mean PSAs vs. white men (7.5 vs. 6.1 ng/mL, p < 0.001). Results were similar after further adjusting for tumor volume: black men had 16% higher mean PSAs versus white men (7.4 vs. 6.2 ng/mL, p < 0.001).
In this study of men undergoing radical prostatectomy at multiple equal access medical centers, racial differences in tumor volume did not explain higher presurgical PSA levels in black versus white men. The exact reason for higher PSA values in black men remains unclear.
Vitamin D<inf>3</inf> supplementation, low-risk prostate cancer, and health disparities
2013, Journal of Steroid Biochemistry and Molecular Biology
Citation Excerpt :
Conversely, vitamin D3 supplementation did not benefit 35–40% of subjects (non-responders), for reasons yet to be investigated. The use of positive cores as an endpoint for pathology outcomes of active surveillance has been reported by the Johns Hopkins group [39]. In this longitudinal study, stipulated adverse pathological features at repeat biopsy included a Gleason score ≥7, or a Gleason pattern grade >4, or >2 positive cores, or >50% cancer involvement of any 1 core.
Vitamin D promotes the differentiation of prostate cancer cells, raising the possibility that vitamin D deficiency over time may contribute to the progression from subclinical prostate cancer to clinical disease. Since low-risk prostate cancers are monitored over time in an effort to determine which progress into clinically important, more aggressive cancers, they provide an excellent model in which to study, over an extended period of time, the effects of enhancing vitamin D status and related changes in tumor progression. This is particularly relevant to African-American men, who exhibit a high prevalence of vitamin D deficiency as well as higher incidence of prostate cancer and higher mortality rates from prostate cancer than Caucasians. Our research team has recently completed an open-label clinical trial aimed at assessing the safety and potential efficacy of vitamin D₃ supplementation at 4000 international units (IU) per day for one year in subjects diagnosed with early stage, low-risk prostate cancer. The results of this clinical study suggest that supplementation with vitamin D₃ at 4000 IU per day may benefit patients with early stage, low-risk prostate cancer on active surveillance, because of the improved outcome (a decreased number of positive cores at repeat biopsy) in more than half of the subjects enrolled in the trial. We also observed that, after one year of supplementation, there was no difference in circulating levels of vitamin D between African-American and Caucasian subjects who completed the study. These clinical results also suggest that robust and sustained vitamin D₃ supplementation can reduce prostate cancer-related health disparities in African-American men and that these health disparities are at least in part the result of widespread hypovitaminosis D within the African-American population.
This article is part of a Special Issue entitled ‘Vitamin D Workshop’.
The importance of tumor palpability and transrectal ultrasonographic appearance in the contemporary clinical staging of prostate cancer
2011, Urologic Oncology: Seminars and Original Investigations
An accurate assessment of the clinical stage of prostate cancer is important to determine the most appropriate treatments for patients. Most centers rely on digital rectal examination, given conflicting results in the literature regarding the role of transrectal ultrasonography (TRUS).
Since ultrasound technologies as well as physician experience have improved, the contemporary impact of TRUS on the clinical staging of prostate cancer was assessed.
In 2002, a standardized form to evaluate TRUS findings in order to rank the clinical suspicion of extracapsular extension (ECE) was used for all prostate cancer patients evaluated at UCSF. Preoperative clinical findings were compared with pathological staging as assessed by analysis of radical prostatectomy specimens from 2002 to 2007 (n = 620).
Mean patient age was 58 ± 6.6 years with a mean PSA of 7.0 ± 4.5; 157/620 (25.3%) had pathologic ECE. Evidence of ECE by TRUS was associated with higher pathologic stage (P < 0.00001) and higher rates of biochemical failure after prostatectomy (P = 0.0006). Overall, TRUS had a 31% sensitivity, 92% specificity, 58% positive predictive value, and 80% negative predictive value with an area under the curve of 0.77 for the detection of ECE. TRUS alone was significantly more accurate in predicting ECE than commonly used nomograms or tables (P < 0.001) when examining patients with impalpable tumors.
In the current era, TRUS provides an accurate method to assess a cancer stage.

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^☆: This study was supported by the Department of Veterans Affairs and a Center for Prostate Disease Research grant from the United States Army Medical Research and Material Command.

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Adult urologyRace as an outcome predictor after radical prostatectomy: results from the Shared Equal Access Regional Cancer Hospital (SEARCH) database☆

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Comment

Conclusions

J Urol

J Urol

Int J Radiat Oncol Biol Phys

J Urol

Urology

J Urol

J Urol

Urology

Adult urology
Race as an outcome predictor after radical prostatectomy: results from the Shared Equal Access Regional Cancer Hospital (SEARCH) database☆