Journal of General Internal Medicine

, Volume 18, Issue 10, pp 845–853

Racial differences in initial treatment for clinically localized prostate cancer

Results from the prostate cancer outcomes study
  • Richard M. Hoffman
  • Linda C. Harlan
  • Carrie N. Klabunde
  • Frank D. Gilliland
  • Robert A. Stephenson
  • William C. Hunt
  • Arnold L. Potosky
Populations At Risk


OBJECTIVE: We examined whether there were racial differences in initial treatment for clinically localized prostate cancer and investigated whether demographic, socioeconomic, clinical, or tumor characteristics could explain any racial differences.

DESIGN: Prospective cohort study.

SETTING: Population-based tumor registries in Connecticut, Los Angeles, and Atlanta.

PARTICIPANTS: We evaluated 1144 African-American and non-Hispanic white men, aged 50 to 74 years, with clinically localized cancer diagnosed between October 1994 and October 1995.

MEASUREMENTS AND MAIN RESULTS: We obtained demographic, socioeconomic, and clinical data from patient surveys and medical record abstractions. We reported adjusted percentages for receiving treatment derived from multinomial logistic regression. We found an interaction between race and tumor aggressiveness. Among men with more aggressive cancers (PSA≥20 ng/mL or Gleason score ≥8), African Americans were less likely to undergo radical prostatectomy than non-Hispanic whites (35.2% vs 52.0%), but more likely to receive conservative management (38.9% vs 16.3%, P=.003). Among the 71% of subjects with less aggressive cancers, African Americans and non-Hispanic whites were equally likely to receive either radical prostatectomy or radiation therapy (80.0% vs 84.5%, P=.2).

CONCLUSIONS: African Americans with more aggressive cancers were less likely to undergo radical prostatectomy and more likely to be treated conservatively. These treatment differences may reflect African Americans’ greater likelihood for presenting with pathologically advanced cancer for which surgery has limited effectiveness. Among men with less aggressive cancers—the majority of cases—there were no racial differences in undergoing radical prostatectomy or radiation therapy.

Key words

prostatic neoplasms prostatectomy radiation therapy patient selection African Americans 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Ries LAG, Eisner MP, Kosary CL, et al. SEER Cancer Statistics Review, 1973–99. Bethesda, MD: National Cancer Institute; 2002.Google Scholar
  2. 2.
    Morton RA, Jr. Racial differences in adenocarcinoma of the prostate in North American men. Urology. 1994;44:637–45.PubMedCrossRefGoogle Scholar
  3. 3.
    Brawn PN, Johnson EH, Kuhl DL, et al. Stage at presentation and survival of white and black patients with prostate carcinoma. Cancer. 1993;71:2569–73.PubMedCrossRefGoogle Scholar
  4. 4.
    Optenberg SA, Thompson IM, Friedrichs P, Wojcik B, Stein CR, Kramer B. Race, treatment, and long-term survival from prostate cancer in an equal-access medical care delivery system. JAMA. 1995;274:1599–605.PubMedCrossRefGoogle Scholar
  5. 5.
    Powell IJ, Schwartz K, Hussain M. Removal of the financial barrier to health care: does it impact on prostate cancer at presentation and survival? A comparative study between black and white men in a Veterans Affairs system. Urology. 1995;46:825–30.PubMedCrossRefGoogle Scholar
  6. 6.
    Ragland KE, Selvin S, Merrill DW. Black-white differences in stage-specific cancer survival: analysis of seven selected sites. Am J Epidemiol. 1991;133:672–82.PubMedGoogle Scholar
  7. 7.
    Merrill RM, Brawley OW. Prostate cancer incidence and mortality rates among white and black men. Epidemiology. 1997;8:126–31.PubMedCrossRefGoogle Scholar
  8. 8.
    Fowler FJ, Jr, McNaughton Collins M, Albertsen PC, Zietman A, Elliott DB, Barry MJ. Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer. JAMA. 2000;283:3217–22.PubMedCrossRefGoogle Scholar
  9. 9.
    Lu-Yao GL, Friedman M, Yao SL. Use of radical prostatectomy among Medicare beneficiaries before and after the introduction of prostate specific antigen testing. J Urol. 1997;157:2219–22.PubMedCrossRefGoogle Scholar
  10. 10.
    Mettlin C. Changes in patterns of prostate cancer care in the United States: results of American College of Surgeons Commission on Cancer Studies, 1974–93. Prostate. 1997;32:221–6.PubMedCrossRefGoogle Scholar
  11. 11.
    Harlan L, Brawley O, Pommerenke F, Wali P, Kramer B. Geographic, age, and racial variation in the treatment of local/regional carcinoma of the prostate. J Clin Oncol. 1995;13:93–100.PubMedGoogle Scholar
  12. 12.
    Schapira MM, McAuliffe TL, Nattinger AB. Treatment of localized prostate cancer in African-American compared with Caucasian men. Less use of aggressive therapy for comparable disease. Med Care. 1995;33:1079–88.PubMedCrossRefGoogle Scholar
  13. 13.
    Klabunde CN, Potosky AL, Harlan LC, Kramer BS. Trends and black/white differences in treatment for nonmetastatic prostate cancer. Med Care. 1998;36:1337–48.PubMedCrossRefGoogle Scholar
  14. 14.
    Quinlan DM, Epstein JI, Carter BS, Walsh PC. Sexual function following radical prostatectomy: influence of preservation of neurovascular bundles. J Urol. 1991;145:998–1002.PubMedGoogle Scholar
  15. 15.
    Horwitz EM, Hanks GE. External beam radiation therapy for prostate cancer. CA Cancer J Clin. 2000;50:349–75.PubMedGoogle Scholar
  16. 16.
    Potosky AL, Harlan LC, Stanford JL, et al. Prostate cancer practice patterns and quality of life: the Prostate Cancer Outcomes Study. J Natl Cancer Inst. 1999;91:1719–24.PubMedCrossRefGoogle Scholar
  17. 17.
    Litwin MS, Hays RD, Fink A, Ganz PA, Leake B, Brook RH. The UCLA Prostate Cancer Index: development, reliability, and validity of a health-related quality of life measure. Med Care. 1998;36:1002–12.PubMedCrossRefGoogle Scholar
  18. 18.
    Talcott JA, Rieker P, Clark JA, et al. Patient-reported symptoms after primary therapy for early prostate cancer: results of a prospective cohort study. J Clin Oncol. 1998;16:275–83.PubMedGoogle Scholar
  19. 19.
    Fowler FJ, Jr, Barry MJ, Lu-Yao G, Roman A, Wasson J, Wennberg JE. Patient-reported complications and follow-up treatment after radical prostatectomy. The Natliona Medicare Experience: 1988–1990 (Updated June 1993). Urology. 1993;42:622–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Charlson ME, Pompei P, Ales KL, Mackenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chron Dis. 1987;40:373–83.PubMedCrossRefGoogle Scholar
  21. 21.
    American Joint Committee on Cancer. Prostate. In: Bears OH, Henson DE, Hutter RVP, Kennedy BJ, eds. AJCC Cancer Staging Manual, 5th edn. Philadelphia, PA: Lippincott-Raven; 1997:219–24.Google Scholar
  22. 22.
    Partin AW, Kattan MW, Subong EN, et al. Combination of prostatespecific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update. JAMA. 1997;277:1445–51.PubMedCrossRefGoogle Scholar
  23. 23.
    Graubard BI, Korn EL. Predictive margins with survey data. Biometrics. 1999;55:652–9.PubMedCrossRefGoogle Scholar
  24. 24.
    Shah BV, Barnwell BG, Bieler GS. SUDAAN User’s Manual, Release 7.5. Research Triangle Park, NC: Research Triangle Institute; 1997.Google Scholar
  25. 25.
    Catalona WJ. Management of cancer of the prostate. N Engl J Med. 1994;331:996–1004.PubMedCrossRefGoogle Scholar
  26. 26.
    Demark-Wahnefried W, Schildkraut JM, Iselin CE, et al. Treatment options, selection, and satisfaction among African American and white men with prostate carcinoma in North Carolina. Cancer. 1998;83:320–30.PubMedCrossRefGoogle Scholar
  27. 27.
    Shaw M, Elterman L, Rubenstein M, McKiel CF, Guinan P. Changes in radical prostatectomy and radiation therapy rates for African Americans and whites. J Natl Med Assoc. 2000;92:281–4.PubMedGoogle Scholar
  28. 28.
    Robbins AS, Whittemore AS, Van Den Eeden SK. Race, prostate cancer survival, and membership in a large health maintenance organization. J Natl Cancer Inst. 1998;90:986–90.PubMedCrossRefGoogle Scholar
  29. 29.
    Desch CE, Penberthy L, Newschaffer CJ, et al. Factors that determine the treatment for local and regional prostate cancer. Med Care. 1996;34:152–62.PubMedCrossRefGoogle Scholar
  30. 30.
    Jones GW, Mettlin C, Murphy GP, et al. Patterns of care for carcinoma of the prostate gland: results of a national survey of 1984 and 1990. J Am Coll Surg. 1995;180:545–54.PubMedGoogle Scholar
  31. 31.
    Mettlin CJ, Murphy GP, Cunningham MP, Menck HR. The National Cancer Data Base report on race, age, and region variations in prostate cancer treatment. Cancer. 1997;80:1261–6.PubMedCrossRefGoogle Scholar
  32. 32.
    Yan Y, Carvalhal GF, Catalona WJ, Young JD. Primary treatment choices for men with clinically localized prostate carcinoma detected by screening. Cancer. 2000;88:1122–30.PubMedCrossRefGoogle Scholar
  33. 33.
    Polednak AP, Flannery JT. Black versus white racial differences in clinical stage at diagnosis and treatment of prostatic cancer in Connecticut. Cancer. 1992;70:2152–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Polednak AP. Prostate cancer treatment in black and white men: the need to consider both stage at diagnosis and socioeconomic status. J Natl Med Assoc. 1998;90:101–4.PubMedGoogle Scholar
  35. 35.
    Fowler JE, Jr, Bigler SA, Bowman G, Kilambi NK. Race and cause specific survival with prostate cancer: influence of clinical stage, Gleason score, age and treatment. J Urol. 2000;163:137–42.PubMedCrossRefGoogle Scholar
  36. 36.
    Imperato PJ, Nenner RP, Will TO. Radical prostatectomy: lower rates among African-American men. J Natl Med Assoc. 1996;88:589–94.PubMedGoogle Scholar
  37. 37.
    Morris CR, Snipes KP, Schlag R, Wright WE. Sociodemographic factors associated with prostatectomy utilization and concordance with the physician data query for prostate cancer (United States). Cancer Causes Control. 1999;10:503–11.PubMedCrossRefGoogle Scholar
  38. 38.
    Shavers VL, Brown ML. Racial and ethnic disparities in the receipt of cancer treatment. J Natl Cancer Inst. 2002;94:334–57.PubMedGoogle Scholar
  39. 39.
    Bach PB, Cramer LD, Warren JL, Begg CB. Racial differences in the treatment of early-stage lung cancer. N Engl J Med. 1999;341:1198–205.PubMedCrossRefGoogle Scholar
  40. 40.
    Epstein AM, Ayanian JZ, Keogh JH, et al. Racial disparities in access to renal transplantation—clinically appropriate or due to underuse or overuse? N Engl J Med. 2000;343:1537–44.PubMedCrossRefGoogle Scholar
  41. 41.
    Ayanian JZ, Cleary PD, Weissman JS, Esptein AM. The effect of patients’ preferences on racial differences in access to renal transplantation. N Engl J Med. 1999;341:1661–9.PubMedCrossRefGoogle Scholar
  42. 42.
    Canto JG, Allison JJ, Kiefe CI, et al. Relation of race and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction. N Engl J Med. 2000;342:1094–100.PubMedCrossRefGoogle Scholar
  43. 43.
    Barry MJ. Prostate-specific-antigen testing for early diagnosis of prostate cancer. N Engl J Med. 2001;344:1373–7.PubMedCrossRefGoogle Scholar
  44. 44.
    Holmberg L, Bill-Axelson A, Helgesen F, et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med. 2002;347:781–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Legler J, Potosky AL, Gilliland FD, Eley JW, Stanford JL. Validation study of retrospective recall of disease-targeted function: results from the prostate cancer outcomes study. Med Care. 2000;38:847–57.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2003

Authors and Affiliations

  • Richard M. Hoffman
    • 1
    • 2
  • Linda C. Harlan
    • 3
  • Carrie N. Klabunde
    • 3
  • Frank D. Gilliland
    • 4
  • Robert A. Stephenson
    • 5
  • William C. Hunt
    • 2
  • Arnold L. Potosky
    • 3
  1. 1.the Medicine ServiceNew Mexico VA Health Care SystemAlbuquerque
  2. 2.the New Mexico Tumor RegistryUniversity of New Mexico Health Sciences CenterAlbuquerque
  3. 3.the Division of Cancer Control and PreventionNational Cancer InstituteBethesda
  4. 4.the Department of Preventive MedicineUniversity of Southern CaliforniaLos Angeles
  5. 5.the Utah Cancer Registry and Division of UrologyUniversity of Utah School of MedicineSalt Lake City

Personalised recommendations