Active Surveillance for Prostate Cancer in “Real-World” Setting: Exploring Racial Disparities

Introduction and objectives: Active surveillance (AS) is a safe management strategy for low-risk prostate cancer (PCa), but limited "real-world" data exist outside trial cohorts. This study investigates racial disparities in progression to treatment, upgrading, and prostate cancer-specific mortality (PCSM) in a real-world AS population, aiming to improve healthcare quality. Methods: We retrospectively analyzed data from the Henry Ford Health System (1995-2023) for men diagnosed with PCa (Gleason Grade ≤ 2, ≤ cT2c, N0-M0, PSA ≤ 20 ng/ml, age < 76 years) and enrolled in AS with ≥ 1 post-diagnosis PSA or biopsy and ≥ 1 year follow-up. Non-Hispanic Blacks (NHBs) and Non-Hispanic Whites (NHWs) were included. Surveillance adequacy was defined as ≥ 1 PSA/year and ≥ 1 biopsy every 4 years. Competing-risk cumulative incidence and regression assessed disparities in progression to treatment, upgrading, and PCSM. Results: Among 864 patients (38% NHBs, 62% NHWs), NHBs presented with more advanced disease, including higher rates of GG2 (29% vs. 18%, p < 0.001) and intermediate-risk PCa (39% vs. 32%, p = 0.04). Surveillance adequacy was lower in NHBs (38% vs. 50%, p < 0.001). NHBs progressed to treatment more frequently (45% vs. 36%, p < 0.001), with a 1.46-fold higher risk (95% CI: 1.14-1.87, p = 0.003). NHBs had no higher odds of upgrading but showed higher 10-year PCSM (5.6% vs. 1.4%) and 5.9-fold higher odds of PCSM (95% CI: 1.38-25.37, p = 0.01). Conclusions: NHBs under AS face more advanced disease, lower follow-up adequacy, higher progression to treatment, and elevated PCSM odds. Targeted strategies are needed to address these disparities and improve equitable PCa care.