Comparison by Race of Conservative Management for Low-Risk and Intermediate-Risk Prostate Cancers in Veterans from 2004 to 2018

Abstract

Importance: Conservative management (ie, active surveillance or watchful waiting) is a guideline-based strategy for men with low-risk and intermediate-risk prostate cancer. However, use of conservative management is controversial for African American patients, who have worse prostate cancer outcomes compared with White patients. Objective: To examine the association of African American race with the receipt and duration of conservative management in the Veterans Health Administration (VA), a large equal-access health system. Design, Setting, and Participants: This cohort study used data from the VA Corporate Data Warehouse for 51543 African American and non-Hispanic White veterans diagnosed with low-risk and intermediate-risk localized node-negative prostate cancer between January 1, 2004, and December 31, 2013. Men who did not receive continuous VA care were excluded. Data were analyzed from February 1 to June 30, 2020. Exposures: All patients received either definitive therapy (ie, prostatectomy, radiation, androgen deprivation therapy) or conservative management (ie, active surveillance or watchful waiting). Main Outcomes and Measures: Receipt of conservative management and (for patients receiving conservative management) time from diagnosis to definitive therapy. Results: The median (interquartile range) age of the 51543 veterans in our cohort was 65 (61-70) years, and 14830 veterans (28.8%) were African American individuals. Compared with White veterans, African American veterans were more likely to have intermediate-risk disease (18988 [51.7%] vs 8526 [57.5%]), 3 or more comorbidities (15438 [42.1%] vs 7614 [51.3%]), and high disability-related or income-related needs (9078 [24.7%] vs 4614 [31.1%]). Overall, 20606 veterans (40.0%) received conservative management. African American veterans with low-risk disease (adjusted relative risk, 0.95; 95% CI, 0.92-0.98; P