Association of Area of Deprivation Index With Active Surveillance (AS) Utilization and Adherence to as Guidelines: Results From a Contemporary North American Cohort.

Abstract

Background: Active Surveillance (AS) for Prostate Cancer (PCa) requires regular follow-up, raising concerns that socioeconomic barriers may result in underutilization or decreased adherence to AS guidelines. We examined the relationship between socioeconomic factors, measured by the Area Deprivation Index (ADI), and AS habits in a contemporary North American cohort.

Methods: We included all the patients aged ≤ 75 years and diagnosed with low (ISUP GG = 1, PSA ≤ 10 ng/mL and cT1N0M0) and intermediate risk (ISUP GG = 2, PSA 10-20 ng/mL or cT2N0M0) PCa at Henry Ford Health (HFH) between 1995 and 2023. An ADI score was assigned to each patient based on their residential census block group, ranked as a percentile of deprivation relative to the national level. The higher the ADI, the more the area has a socioeconomic disadvantage. Logistic regression analysis tested the impact of ADI on AS utilization and adherence to AS guidelines. Only patients who underwent at least 1 PSA test per year and at least 1 biopsy every 4 years were considered as "adherent to guidelines".

Results: Our final cohort consisted of 4376 patients eligible for AS, 919 of whom actually underwent AS. Older patients (66 vs. 62 years, p < 0.0001) and those diagnosed in more recent years (2017 vs. 2010, p < 0.0001) had higher probability to undergo AS. Moreover, patients in the AS group more likely to be NHB (36% vs. 25%, p < 0.0001), had higher ADI score (61 vs. 55, p < 0.0001), more comorbidities according to Charlson Comorbidity Index (CCI) score, (19.5%% vs. 13.8%, p < 0.0001) and higher probability to harbor low risk PCa (65.7% vs. 26.6%, p < 0.0001), compared to patients who underwent active treatment. Among the 919 patients in AS, only 410 were "adherent to guidelines". Patients following guidelines were more likely to be NHW (64.1% vs. 52.8%, p < 0.003), and had lower ADI percentile (55.5 vs. 66, p < 0.0003). Furthermore, AS patients managed according to the prevailing guidelines received more PSAs tests (1.8 vs. 0.8, p < 0.0001) and prostate biopsies (0.3 vs. 0.0, p < 0.0001) per year, thus reporting both higher upgrading rates during AS (35.6% vs. 23%, p < 0.0001) and an increased probability to undergo active treatment (48% vs. 27%, p < 0.0001). At MVA, patients with a higher ADI score reported higher probability to undergo AS (OR: 1.06, 95% CI: 1.02-1.10, p = 0.004), but at the same time they were less likely to follow AS' guidelines (OR: 0.94, 95% CI: 0.89-0.99, p = 0.02).

Conclusions: Patients in the most deprived areas had a higher likelihood of undergoing AS but were more prone to receive guideline-discordant care. This should be taken into consideration by physicians when recommending AS for those men living in the least advantaged neighborhoods. Our study highlights the need for targeted community reforms to enhance proper and informed AS utilization among socioeconomically disadvantaged populations.