Incidence and Mortality Rate Trends of Metastatic Prostate Cancer, SEER Analysis from 2008-2016 Aaron C.
1 Zhang ,
Rehana Rasul 1Donald
2 MA ,
Anne Golden
2 PhD ,
and Michael A.
3 Feuerstein
and Barbara Zucker School of Medicine at Hofstra/Northwell 2Feinstein Institutes for Medical Research, Department of Occupational Medicine, Epidemiology and Prevention, Zucker School of Medicine at Hofstra/Northwell 3Lenox Hill Hospital, Department of Urology, Zucker School of Medicine at Hofstra/Northwell
Background
Results
Discussion
o Prostate cancer is the most common cancer diagnosed in men in the U.S. with an estimated 191,000 new cases in 2020. o Metastatic prostate cancer (mPCa) remains the second leading cause of cancer-related death in men with a 5-year relative survival rate of 30.2%.1 o The 2012 United States Preventative Services Task Force (USPSTF) recommendation against routine prostate cancer screening may have contributed to an increase in diagnosis of de novo mPCa in recent years. o Docetaxel and other new drugs have demonstrated survival benefit as first-line agents for treating mPCa3and the impact of decreased screening and novel treatments on patient survival has yet to be fully explored. o Considering that race/ethnicity and socioeconomic status have been shown to influence incidence and mortality of cancer4, 5, we examined demographic differences in incidence of de novo mPCa and survival between 2008-2016.
o The increase in incidence of mPCa after 2012 is likely related to reduced screening and/or access to care.6 o We found a significant increase in incidence among certain groups, most notably those who were non-Hispanic White, lived in communities 0-10% below federal poverty level, and 75-84 years old. o Certain subgroups demonstrated an increased risk of cancer-specific mortality, notably married men and men who lived in counties >20% below federal poverty level.
o We hypothesize that non-Hispanic Whites, men who lived in counties 0-10% below poverty level, i.e., not impoverished, and men over 65, the age that Medicare begins, likely had better access to screening in the past and therefore were impacted the most during this time period. o Despite increases in mPCa incidence over time, the risk of prostate cancer-specific mortality decreased in later time intervals, which may reflect the recent advances in treatment for prostate cancer and/or improved access to care through the Patient Protection and Affordable Care Act, enacted in 2010. o Men who were insured demonstrated a lower risk of prostate cancer-specific mortality compared to those who were uninsured. o Not only is there an increased likelihood of advanced prostate cancer in uninsured patients compared to insured patients, but also insurance status acts as an important predictor for favorable treatment outcomes in patients with low grade disease.7 o Unmarried men may lack the social support systems that are critical for cancer treatment and survival. o Men living in areas below poverty level (>20%) likely suffer from lack of access to cancer-related treatments and care, contributing to significantly higher risk of both prostate cancerspecific and all-cause mortality.8
Hypothesis We hypothesized that decreased prostate cancer screening and the advent of novel therapies changed population trends of de novo mPCa incidence and survival within different demographic groups.
Methods o Data was queried from the Surveillance, Epidemiology, and End Results (SEER) Program SEER 18 Registries Research Data + Hurricane Katrina Impacted Louisiana cases based on the November 2018 submission using SEER*Stat 8.3.6 software. o mPCa incidence rates and standard errors among males 45 years or older during 2008-2016 were extracted. o Metastatic cases were classified using the AJCC 6 staging criteria for 2008-2015 and AJCC 7 staging criteria for 2016. o Multivariable Poisson regression models were used to evaluate whether mPCa incidence rates differed by period, while adjusting for demographic variables and tumor stage. o Multivariable Cox proportional hazards models were used to determine whether there was a difference in all-cause mortality and prostate cancer mortality between time periods and whether it was modified by demographic variables or stage.
Table 1. Patient Characteristics Variable
Total (n = 24,407)
Table 2. Adjusted metastatic prostate cancer incidence rate ratios by demographic subgroups, stage at diagnosis, and period, SEER 2008-2016
n (%) Age group 45-54 years 55-64 years 65-74 years 75-84 years 85+ years Marital Status Married Unmarried Unknown Insurance Status Uninsured Insured Insurance status unknown Geographic Region Alaska, Pacific Coast East Northern Plains Southwest Race/Ethnicity Non-Hispanic White Non-Hispanic Black Non-Hispanic American Indian/Alaska Non-Hispanic Asian or Pacific Island Hispanic (All Races) Poverty Level 0%-10% >10%-15% >15%-20% >20% Stage M1a M1b M1c
1513 (6.2) 5615 (23) 7236 (29.6) 6426 (26.3) 3617 (14.8) 13930 (57.1) 8832 (36.2) 1645 (6.7) 840 (3.4) 22709 (93) 858 (3.5) 12396 (50.8) 8535 (35) 2385 (9.8) 1091 (4.5) 15845 (64.9) 4271 (17.5) 165 (0.7) 1404 (5.8) 2722 (11.2) 5060 (20.7) 8136 (33.3) 7583 (31.1) 3628 (14.9) 1502 (6.2) 18124 (74.3) 4781 (19.6)
Figure 1. Adjusted metastatic prostate cancer incidence rates, SEER 2008-2016
Estimated Incidence Rate Ratios (CI) per 100,000 (ref=2008-2009) Overall Age group 45-54 years 55-64 years 65-74 years 75-84 years 85+ years Poverty Level 0%-10% >10%-15% >15%-20% >20% Race/Ethnicity Hispanic (All Races) Non-Hispanic American Indian/Alaska Non-Hispanic Asian or Pacific Islander Non-Hispanic Black Non-Hispanic White Region East Northern Plains Alaska, Pacific Coast Southwest Stage M1a M1b M1c
2010-2011 1.02 (0.98-1.05)
2012-2013 1.09 (1.06-1.13)
2014-2016 1.18 (1.14-1.21)
1.05 (0.93-1.19) 0.98 (0.92-1.05) 1.08 (1.01-1.14) 1.03 (0.97-1.09) 0.93 (0.86-1.01)
1.03 (0.91-1.17) 1.06 (0.99-1.13) 1.11 (1.05-1.18) 1.11 (1.05-1.18) 1.12 (1.03-1.21)
1.16 (1.04-1.30) 1.13 (1.07-1.20) 1.20 (1.14-1.27) 1.24 (1.18-1.31) 1.10 (1.02-1.18)
1.07 (0.99-1.16) 1.04 (0.99-1.10) 0.97 (0.92-1.02) 1.01 (0.93-1.10)
1.15 (1.07-1.25) 1.11 (1.05-1.17) 1.05 (0.99-1.10) 1.12 (1.03-1.21)
1.31 (1.22-1.40) 1.19 (1.14-1.25) 1.10 (1.05-1.16) 1.18 (1.10-1.27)
0.98 (0.89-1.08) 0.93 (0.62-1.39) 0.79 (0.69-0.91) 1.01 (0.94-1.09) 1.04 (1.00-1.09)
1.06 (0.96-1.16) 1.15 (0.79-1.68) 0.94 (0.82-1.06) 1.01 (0.94-1.09) 1.14 (1.10-1.19)
1.00 (0.92-1.09) 1.14 (0.80-1.6) 1.00 (0.90-1.13) 1.05 (0.98-1.12) 1.27 (1.22-1.31)
1.06 (1.00-1.12) 1.11 (1.00-1.23) 0.96 (0.92-1.01) 1.08 (0.92-1.27)
1.10 (1.04-1.16) 1.17 (1.05-1.29) 1.06 (1.02-1.11) 1.32 (1.13-1.54)
1.22 (1.16-1.28) 1.29 (1.18-1.41) 1.12 (1.07-1.16) 1.39 (1.21-1.59)
1.09 (0.95-1.25) 1.08 (1.04-1.12) 0.82 (0.76-0.87)
1.20 (1.05-1.37) 1.17 (1.13-1.21) 0.87 (0.81-0.93)
1.62 (1.44-1.82) 1.25 (1.21-1.29) 0.88 (0.83-0.93)
Table 3. Multivariable Cox proportional hazards models for prostate cancerspecific mortality in men with metastatic prostate cancer, SEER 2008-2014. Prostate Cancer Mortality HR Period (ref = 2008-2009) 2010-2011 2012-2014 Age group (ref = 20-54 years) 55-64 years 65-74 years 75-84 years 85+ years
P Value
0.96 (0.92-1.01) 0.93 (0.89-0.97)
0.09 0.002
0.99 (0.91-1.07) 1.10 (1.01-1.19) 1.52 (1.41-1.65) 2.31 (2.13-2.51)
0.7 0.02 <.0001 <.0001
0.88 (0.80-0.97) 0.91 (0.80-1.04)
0.01 0.2
1.23 (1.19-1.28) 0.99 (0.92-1.06)
<.0001 0.7
1.01 (0.97-1.05) 1.00 (0.94-1.06) 0.94 (0.86-1.03)
0.8 0.9 0.2
1.04 (0.99-1.09) 1.04 (0.84-1.28) 0.77 (0.71-0.84) 0.95 (0.89-1.00)
0.1 0.7 <.0001 0.06
1.00 (0.95-1.05) 1.04 (0.99-1.09) 1.10 (1.04-1.17)
1 0.2 0.002
Insurance Status (ref = uninsured) Insured Insurance status unknown Marital Status (ref = Married) Figure 2. Adjusted metastatic prostate cancer incidence Unmarried rates by stage at diagnosis, SEER 2008-2016 Unknown Geographic region (ref = East) Figure 7: Independent CRISPR knockout of CDK4 or CDK6Alaska, Pacific Coast does not cause dropout in most breast cancer cell lines Northern Plains Southwest studied. Race/Ethnicity (ref = White) Non-Hispanic Black Non-Hispanic American Indian/Alaska Native Non-Hispanic Asian or Pacific Islander Hispanic (All Races) Poverty Level (ref = 0-10%) >10%-15% >15%-20% >20%
Future Direction o This study was unable to assess if screening guidelines were implemented for individual cases and can only make inferences based on time periods. o SEER data does not include important risk factors and clinical factors that may act as confounders. o Future studies should examine the impact of more recent USPTSF guidelines for reinstituting screening and implementation of newer prostate cancer therapies in different subgroups. o Studies using more granular data including treatment information and insurance status should be considered to examine trends in incidence and mortality of mPCa.
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