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Clinical and Socioeconomic Disadvantaged Socioeconomic Status is Strongly Associated with Metastatic Prostate Cancer
Jared P. Schober, MD, Kristian D. Stensland, MD, Alireza Moinzadeh, MD, David Canes, MD.
Lahey Hospital and Medical Center, Burlington, MA, USA.

BACKGROUND
Since the USPSTF recommendations against PSA screening in 2008 and 2012, there is renewed interest in focusing screening efforts towards at-risk populations in order to identify clinically significant disease. As such, defining characteristics associated with patients ultimately developing metastatic disease is valuable. Other than the well recognized association between African American race and aggressive prostate cancer (PCa), patient demographics are underexplored. We used a large hospital-based database to describe socioeconomic characteristics at diagnosis of metastatic prostate cancer.
METHODS
The National Cancer Database (NCDB) was used to examine PCa diagnoses from 2004-2014. To minimize reporting bias, only hospitals contributing at least one case per year for the entire decade were included. Cases with clinical M1 disease were defined as metastatic. No changes to the diagnostic criteria of M1 disease were made during this time. A robust multivariate regression model was created to assess the relationship of M1 disease with included covariates: year of diagnosis, age, race, income, regional insurance and education status, Charlson-Deyo index, and PSA at diagnosis.
RESULTS
A total of 1,235,869 cases of incident PCa were included, of which 49,586 (4.01%) were metastatic. The NCDB captured a declining proportion of total PCa cases in the US (cancer.org) year over year, from 68% in 2004 to 38% in 2014. Patients with medicaid or uninsured had the highest odds of bearing metastatic disease (OR 3.35 and 4.33, respectively) compared to private insurance (p < 0.001). Other factors associated with metastasis include African American race (OR 1.31, p < 0.001), more recent year of diagnosis (OR 1.12 per year vs 2004, p < 0.001), income <$38,000 (OR 1.12 vs >$63,000, p < 0.001) and PSA >20 at diagnosis (OR 9.37 vs PSA < 4, p < 0.001).
CONCLUSIONS
Our data support well known associations of high PSA and African American race with metastatic prostate cancer. Of interest, disadvantaged socioeconomic status (low income, no insurance, medicaid) is associated with metastatic disease at initial diagnosis. In addition to patient education and selective screening, efforts must be made to address upstream issues impacting early detection in disadvantaged patients who may have suboptimal access to care.


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