Introduction:

In recent years, active surveillance has emerged as the gold standard management strategy for low-risk and selective intermediate-risk prostate cancer (PCa). Concurrently, the utilization of the Social Vulnerability Index (SVI) is reshaping and informing our understanding of disadvantage and social vulnerability within the landscape of cancer care. In this study, we investigated the intersection of active surveillance and social vulnerability in low and intermediate-risk prostate cancer. 

Methods:

Men diagnosed with localized, low and intermediate risk prostate cancer (ie, those potentially eligible for active surveillance) from 1998-2017 within the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) database were identified. Data for participants in the CaPSURE registry were geocoded, deidentified, and combined with publicly available Social Vulnerability Index (SVI) data, assessing community vulnerability with 15 social factors captured under four themes: socioeconomic status, household composition and disability, minority status and language, and housing and transportation. We conducted multinomial logistic regression modeling to examine the association between the Social Vulnerability Index (SVI) and treatment types: Radical Prostatectomy (RP), Brachytherapy (BT), External Beam Radiation Therapy (EBRT), Hormonal therapy, and Watchful Waiting/Active Surveillance (WWAS). 

Results:

 Among 6394 low-risk and intermediate-risk prostate cancer patients from 1998-2017, there was an overall decline in traditional therapies (RP, BT, EBRT, Hormonal) and a shift towards increased WWAS utilization. In recent years (2010-2017), WWAS was less likely to be the initial management strategy selected for patients with high SVI due to Socioeconomic status compared to patients with low SVI by Socioeconomic status (26.2% vs 35.5%). This differential increased for those in areas of high SVI due to racial and ethnic minority density compared to low SVI (21.4% vs 34.4%, p=0.0047, Figure 1).

Conclusion:

For patients with low and intermediate risk localized prostate cancer, patients with high SVI, particularly those residing in areas of greater racial and ethnic minority status, being treated more frequently with invasive forms of treatment rather than active surveillance. In this manner, active surveillance eligible patients may be at greater risk of overtreatment of potentially indolent disease. Researching management of malignancies such as prostate cancer through the lens of social vulnerability indices can both identify communities at greater risk of overtreatment and aid in focusing efforts to improve active surveillance utilization using targeted implementation strategies.

Funding: UCSF Prostate Cancer Program Pilot Research Award, UCSF Goldberg-Benioff Program in Cancer Translational Biology, Steven & Christine Burd Safeway Distinguished Professorship, Goldberg-Benioff Endowed Professorship in Cancer Biology, Movember Prostate Cancer Health Equity Grant