br positive surgical margins vs
.01), positive surgical margins (35.3% vs. 22.1%; P < .01), and adverse pathology (41.4% vs. 30.1%; P ¼ .03). Linear and logistic regression showed significant inverse associations of SES with CAPRA-S score (P < .01) and adverse pathology (P ¼ .03). Conclusion: In a GSK126 of AA men who underwent RP, we observed an independent as-sociation of low SES with advanced stage or aggressive prostate cancer. By including only patients in a single racial demographic group, we eliminated the potential confounding effect of race on the association between SES and prostate cancer risk. These findings suggest that impoverished populations might benefit from more intensive screening and early, aggressive treatment of prostatic malignancies.
Keywords: African American, Disparities, Poverty, Prostatic neoplasms, Race
1Department of Urology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 2Division of Urology, University of Pennsylvania Health System, Philadelphia, PA
Address for correspondence: Adam C. Reese, MD, Department of Urology, Lewis Katz School of Medicine at Temple University, 3401 N Broad St Zone C, Suite 340, Philadelphia, PA 19140 E-mail contact: [email protected]tuhs.temple.edu
Poverty and Adverse Prostate Cancer Pathology
African American (AA) men are disproportionately affected by aggressive prostate cancer. According to a recent analysis of the Surveillance, Epidemiology, and End Results database from 2009 to 2013, the highest number of new prostate cancer cases (203.5 per 100,000) and the greatest number of deaths from prostate cancer (44 per 100,000) occur among men of AA race.1 Furthermore, AA men typically present at a younger age and with more advanced disease compared with their Caucasian counterparts.
Low socioeconomic status (SES) has also been linked to prostate cancer burden. Population-based studies have shown an inverse rela-tionship between income status and clinical risk of prostate cancer at diagnosis, as well as overall prognosis.2-4 Because of confounding as-sociations between income and race, however, the independent contribution of income, irrespective of race, remains unclear.5-7
We hypothesized that an independent association between low SES and adverse prostate cancer pathology would remain after eliminating potential confounding between SES and race. In the current study, we retrospectively analyzed a multi-institutional ur-ban population comprised exclusively of AA men who underwent primary therapy with radical prostatectomy (RP). To our knowl-edge, this is the first study to examine the independent effects of income status on prostate cancer aggressiveness. Awareness that patients from low-income households are at higher risk of prostate cancer recurrence and progression can be used to identify individual patients who are targets for more intensive screening and early, aggressive treatment of prostatic malignancies.
Patients and Methods
We reviewed prospectively maintained prostate cancer databases from 2 academic medical centers after approval by each site’s institutional review board. Both databases record demographic and disease-specific data on all prostate cancer patients with the primary population residing in urban Philadelphia. We included all AA men diagnosed with clinically localized prostate cancer between 2010 and 2015 who underwent RP as initial therapy. Patients with missing demographic or pathologic data were excluded. All racial and ethnicity data were self-reported by patients before inclusion in the database. More than 95% of radical prostatectomies were per-formed in robotic-assisted fashion and this percentage did not differ between the 2 institutions.
The 2 academic medical centers included in this analysis are based in urban Philadelphia with catchment areas that encompass large portions of the Delaware Valley region, a racially and so-cioeconomically diverse area that includes southeastern and central Pennsylvania, southern New Jersey, and parts of Dela-ware. AA men treated at either institution were included regardless of the geographic location of their home. Because of the location of the 2 institutions in Philadelphia, a large per-centage of men reside in urban, primarily AA communities within Philadelphia.
Assessment of Household Income
Household income for each patient was estimated as the median income for the census tract that contained his residential mailing
address. Census tracts are small geographic areas designed to average approximately 4000 people per census tract. These census tracts are similar to residential Zip codes, but encompass smaller areas, therefore resulting in increased granularity and more accurate representations of household income. The literature has shown census tract data to correlate with other measures of SES, and census tract data are often used to estimate household income when individual patient income is not known.8-10 The census tract median income for each patient’s residential mailing address was determined using the ArcGIS census tract database (Esri; available at www.arcgis.com; accessed May 16, 2016). Income amounts are expressed in current US dollars, including an adjustment for inflation and cost of living increases.