Examining community social vulnerability domains and influence on treatment selection for men with prostate cancer.

Abstract

363 Background: For men with clinically localized PCa, treatment selection guided by patient age, comorbidities, and tumor characteristics can offer improved outcomes. While informative, these observations remain difficult to translate into local, state, and federal policy change to eliminate health disparities for communities at greater risk. We sought to examine how community SVI influences primary treatment, a key determinant of cancer outcomes, for men with clinically localized PCa treated primarily in a community setting. Methods: Men diagnosed and managed in CaPSURE practices after 1998 with clinically localized disease (no cM+ or cT4) and who underwent primary management within six months of diagnosis were identified. Community social vulnerability, as defined by census tract-level rankings from 0 to 1 with >90 th percentile deemed high, was appended to participants’ geocoded baseline addresses. SVI encompasses four domains (socioeconomic status, household characteristics, racial and ethnic minority status, and housing type and transportation). Prostate cancer treatment included prostatectomy, radiation, active surveillance/watchful waiting (AS/WW), primary androgen deprivation therapy (pADT). Multivariate multinomial logistic regression analyses examined associations between SVI and treatment selection, adjusted for patient, clinical, and tumor characteristics with sensitivity analyses using each SVI domain. Odds ratios and confidence intervals were reported with a two-sided p-value < 0.05 considered significant. Analysis was performed with SAS 9.4 for Windows. Results: 9,023 men diagnosed with low (43%) or intermediate (42%) risk disease and treated at community urology practices (90%) were included. Half (52%) underwent prostatectomy, 26% radiation, 13% ADT, and 9% AS/WW. Median SVI was 0.37 (IQR 0.17-0.59) and varied by theme: socioeconomic status (median 0.35, IQR 0.18-0.57), household characteristics (median 0.41, IQR 0.22-0.64), racial and ethnic minority status (median 0.37, IQR 0.17-0.63), and housing type and transportation (median 0.44, IQR 0.21-0.70). Correlations between SVI themes varied broadly (r = 0.21-0.63, p < 0.001). Having high SVI was associated with increased odds of non-invasive treatment compared to RP: RT (OR 1.56, 95% CI 1.39-1.77), AS/WW (OR 1.21, 95% CI 1.0-1.45), or pADT (OR 1.51, 95% CI 1.27-1.79). Individuals with high SVI by household characteristics had significantly greater likelihood of pADT (OR 1.61, 95% 1.34-1.94) compared to RP. Conclusions: Community social vulnerability independently increases the likelihood of non-surgical and potentially non-curative management of prostate cancer. SVI domains can provide specificity into which community characteristics may drive vulnerability and aid in identifying communities for targeted, policy-focused interventions.