AUA2023 BEST POSTERS Racial and Ethnic Disparities in Valuation of Life Expectancy in Prostate Cancer Treatment Decision-making

By: John M. Masterson, MD, Cedars-Sinai Medical Center, Los Angeles, California; Michael Luu, MPH, Cedars-Sinai Medical Center, Los Angeles, California; Rebecca Gale, MPH, Cedars-Sinai Medical Center, Los Angeles, California; Brennan Spiegel, MD, MSHS, Cedars-Sinai Medical Center, Los Angeles, California; Stephen J. Freedland, MD, Cedars-Sinai Medical Center, Los Angeles, California; Timothy J. Daskivich, MD, MSHPM, Cedars-Sinai Medical Center, Los Angeles, California | Posted on: 30 Aug 2023

Previous studies have shown that Black and Hispanic men are more often overtreated for low-risk cancer compared to non-Hispanic White men.1 While overtreatment of these men may be due to both provider and patient factors, it is possible that Black and Hispanic men value trade-offs related to prostate cancer treatment differently than others. One of these key trade-offs is life expectancy (LE), which predicts the likelihood that men will have sufficient longevity to benefit from prostate cancer treatment.2 AUA guidelines recommend watchful waiting for asymptomatic men with limited LE, but support surgery or radiation for men with intermediate- or high-risk disease and LE beyond 10 years.3

We conducted a study to investigate racial and ethnic disparities in how Black and Hispanic men value LE compared to other races in prostate cancer treatment decision-making. We crowdsourced a conjoint analysis exercise to a general-public population of men who demographically represent a typical U.S. prostate cancer population based on SEER (Surveillance, Epidemiology, and End Results)–Medicare data. A conjoint analysis is a form of trade-off analysis that was originally designed for market analysis in how consumers make complex purchasing decisions. Our conjoint analysis exercise required men to iteratively choose between aggressive vs nonaggressive treatment for prostate cancer across varying levels of tumor risk and risk of side effects (Figure 1). These men were instructed to consider their LE as calculated by the Prostate Cancer Comorbidity Index (PCCI), a validated longevity prediction tool, when making these decisions.4 We compared the association of Black race and Hispanic ethnicity with treatment choice across levels of LE using multinominal logistic regression analysis.

Figure 1. Conjoint analysis exercise with varying levels of attributes related to treatment vs nontreatment of localized prostate cancer.

A total of 2,046 men completed the conjoint analysis, of whom 435 (22%) were Black and 230 (11%) were Hispanic. Most of the population (88%) was extremely or quite health literate according to the Single-Item Literacy Screener,5 and there was no difference in health literacy by race or ethnicity. Participants matched the typical demographic of comorbidity of a U.S. population with localized prostate cancer according to the PCCI; 617 (30.2%), 468 (22.9%), 430 (21%), and 531 (26%) men had PCCI scores of 0, 1, 2, and 3+ respectively.

Overall, longer LE was strongly associated with aggressive treatment choice; the odds of an aggressive treatment choice increased by 17% for every 5 years of additional LE (OR 1.17, 95% CI 1.12-1.22; Figure 2). However, among Black men, LE was not associated with treatment choice (OR 0.97, 95% CI 0.90-1.05; Figure 3, A). Black men were also more likely to choose aggressive treatment than other subgroups regardless of LE or tumor risk. Conversely, LE was strongly associated with treatment choice in Hispanic men (OR 1.14, 95% CI 1.02-1.27), similar to the overall population (Figure 3, B).

Figure 2. Odds ratio of treatment vs no treatment for clinically localized prostate cancer by patient life expectancy.
Figure 3. Odds ratio for aggressive treatment choice by life expectancy across Black vs Non-Black men (A) and Hispanic vs Non-Hispanic Men (B).

Our data suggest that Black men may value LE differently than men of other races, which may be a contributing factor to overtreatment in these populations. There may be several explanations for why this is the case. One possibility is that Black men interpret these data differently than other groups. Another possibility is that cultural practices of Black men promote aggressive treatment of cancer regardless of absolute benefits of treatment. Yet another possibility is that Black men don’t prefer quantitative comparisons of risk such as those posed in the conjoint exercise.

Though our data are unable to identify a particular reason for why Black men place less value on LE, they call for further study to elucidate the cause. Better understanding of the reasons underlying this preference will allow for development of a culturally sensitive approach to communicating LE in order to reduce overtreatment of Black men.

  1. Butler S, Muralidhar V, Chavez J, et al. Active surveillance for low-risk prostate cancer in Black patients. N Engl J Med. 2019;380(21):2070-2072.
  2. Daskivich TJ, Lai J, Dick AW, et al. Variation in treatment associated with life expectancy in a population-based cohort of men with early-stage prostate cancer. Cancer. 2014;120(23):3642-3650.
  3. Eastham JA, Auffenberg GB, Barocas DA, et al. Clinically localized prostate cancer: AUA/ASTRO guideline, part I: introduction, risk assessment, staging, and risk-based management. J Urol. 2022;208(1):10-18.
  4. Daskivich TJ, Thomas IC, Luu M, et al. External validation of the prostate cancer specific comorbidity index: a claims based tool for the prediction of life expectancy in men with prostate cancer. J Urol. 2019;202(3):518-524.
  5. Morris NS, MacLean CD, Chew LD, Littenberg B. The single item literacy screener: evaluation of a brief instrument to identify limited reading ability. BMC Fam Pract. 2006;7(1):21.