br Margins br Negative br Positive br Extraprostatic br Exte
Data are presented as n (%) except where otherwise noted.
a ¼ postsurgical Cancer of the Prostate Risk Assessment.
Adverse Pathology: pathological stage pT3, Gleason score 4þ3, or positive HG 9 91 01 nodes.
Figure 1 shows the distribution of CAPRA-S scores and rates of adverse pathology with men stratified according to quartile of in-come. CAPRA-S scores and rates of adverse pathology were inversely associated with income level. A scatterplot of CAPRA-S score versus income level for each individual patient is shown in Figure 2, where an inverse association was again observed.
Linear regression modeling showed an independent inverse relationship between household income and CAPRA-S score (coefficient, 0.15; 95% confidence interval [CI], 0.25 to 0.05; P < .01). Lower income in this population of AA men was also a significant predictor of adverse pathology after RP in logistic regression analysis (odds ratio, 0.90; 95% CI, 0.83-0.99; P ¼ .03).
The current analysis of AA men who underwent RP at 2 large academic medical centers showed that low SES was independently associated with adverse prostate cancer pathology. AA men living in low-income households were found to have higher preoperative PSA values as well as higher pathologic T stage, rates of SVI, positive surgical margins, and CAPRA-S scores than their counterparts from high-income households.
Other studies have suggested an association between low SES and adverse prostate cancer outcomes.2-5 Impoverished men of various races have been shown to have higher PSA values and Gleason scores at diagnosis,2,3 a greater likelihood of metastatic disease,2 and decreased cancer-specific survival.4 These observations are poten-tially confounded, however, by the substantial correlation between race and SES5-7 whereby AA men tend to have lower SES and inferior prostate cancer outcomes. Several previous studies have shown that prostate cancer racial disparities are potentially attenu-ated after adjusting for socioeconomic factors.12,13 These studies suggest a strong inter-relationship between race and SES, with both factors potentially contributing to adverse prostate cancer outcomes in impoverished, minority patients. Importantly, in the current study we controlled for the confounding factor of race by limiting inclusion criteria to members of a single minority demographic ethnicity.
In the published literature it has also been speculated that racial differences in treatment modalities and intensity might explain the inferior prostate cancer outcomes seen in AA men compared with Caucasian men. For example, previous studies have shown that black men are less likely to undergo surgery or radiation therapy for
prostate cancer, which might result in suboptimal cancer con-trol.14,15 An additional advantage of our analysis is that all patients were treated with RP, minimizing any potential confounding effect of differing treatment modalities.
The exact mechanisms underlying the link between low SES and advanced-stage prostate cancer are not entirely clear, although di-etary factors, obesity, environmental stressors, and differential screening practices/access to care have all been implicated.16-23 Previous studies have shown that chronic poverty can result in
4 - Clinical Genitourinary Cancer Month 2019
Samuel A. Weprin et al
Figure 1 (A) Postsurgical Cancer of the Prostate Risk Assessment (CAPRA-S) Risk Scores According to Income Quartile. (B) Rates of Adverse Pathology According to Income Quartile. CAPRA-S Scores and Rates of Adverse Pathology Are Inversely Associated With Income Level
food insecurity, ultimately resulting in overnutrition and obesity, a condition that might be further exacerbated by the lack of diversi-fied dietary choices in impoverished communities.22 Obesity, in turn, has been implicated in the development of high-grade tu-mors,17 as well as an increased risk of death from prostate cancer.24 Furthermore, low SES often results in chronic psychosocial stress, a condition thought to increase systemic inflammation and decrease immunity, conditions that might promote carcinogenesis.16,20 Finally, AA men in low-income communities might be less likely to undergo prostate cancer screening because of poor education, lack of access to health care, distrust of medical professionals, and beliefs regarding cancer fatalism.18,25 Although each of these factors likely contribute to the increased risk of aggressive cancers in impov-erished men, further study is clearly needed to elucidate the exact mechanisms linking poverty to advanced prostate cancer. Identifi-cation of these mechanisms might allow for targeted intervention in impoverished communities to decrease prostate cancer morbidity and mortality in these populations.