Original Research

Impact of Race on Outcomes of High-Risk Patients With Prostate Cancer Treated With Moderately Hypofractionated Radiotherapy in an Equal Access Setting

Fed Pract. 2022 August;39(3):S35-S41 | 10.12788/fp.0305

References

2. Jaworski L, Dominello MM, Heimburger DK, et al. Contemporary practice patterns for intact and post-operative prostate cancer: results from a statewide collaborative. Int J Radiat Oncol Biol Phys. 2019;105(1):E282. doi:10.1016/j.ijrobp.2019.06.1915

3. Miralbell R, Roberts SA, Zubizarreta E, Hendry JH. Dose-fractionation sensitivity of prostate cancer deduced from radiotherapy outcomes of 5,969 patients in seven international institutional datasets: α/β = 1.4 (0.9-2.2) Gy. Int J Radiat Oncol Biol Phys. 2012;82(1):e17-e24. doi:10.1016/j.ijrobp.2010.10.075

4. Tree AC, Khoo VS, van As NJ, Partridge M. Is biochemical relapse-free survival after profoundly hypofractionated radiotherapy consistent with current radiobiological models? Clin Oncol (R Coll Radiol). 2014;26(4):216-229. doi:10.1016/j.clon.2014.01.008

5. Brenner DJ. Fractionation and late rectal toxicity. Int J Radiat Oncol Biol Phys. 2004;60(4):1013-1015. doi:10.1016/j.ijrobp.2004.04.014

6. Tucker SL, Thames HD, Michalski JM, et al. Estimation of α/β for late rectal toxicity based on RTOG 94-06. Int J Radiat Oncol Biol Phys. 2011;81(2):600-605. doi:10.1016/j.ijrobp.2010.11.080

7. Dasu A, Toma-Dasu I. Prostate alpha/beta revisited—an analysis of clinical results from 14 168 patients. Acta Oncol. 2012;51(8):963-974. doi:10.3109/0284186X.2012.719635 start

8. Proust-Lima C, Taylor JMG, Sécher S, et al. Confirmation of a Low α/β ratio for prostate cancer treated by external beam radiation therapy alone using a post-treatment repeated-measures model for PSA dynamics. Int J Radiat Oncol Biol Phys. 2011;79(1):195-201. doi:10.1016/j.ijrobp.2009.10.008

9. Lee WR, Dignam JJ, Amin MB, et al. Randomized phase III noninferiority study comparing two radiotherapy fractionation schedules in patients with low-risk prostate cancer. J Clin Oncol. 2016;34(20): 2325-2332. doi:10.1200/JCO.2016.67.0448

10. Dearnaley D, Syndikus I, Mossop H, et al. Conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer: 5-year outcomes of the randomised, non-inferiority, phase 3 CHHiP trial. Lancet Oncol. 2016;17(8):1047-1060. doi:10.1016/S1470-2045(16)30102-4

11. Catton CN, Lukka H, Gu C-S, et al. Randomized trial of a hypofractionated radiation regimen for the treatment of localized prostate cancer. J Clin Oncol. 2017;35(17):1884-1890. doi:10.1200/JCO.2016.71.7397

12. Pollack A, Walker G, Horwitz EM, et al. Randomized trial of hypofractionated external-beam radiotherapy for prostate cancer. J Clin Oncol. 2013;31(31):3860-3868. doi:10.1200/JCO.2013.51.1972

14. Wilkins A, Mossop H, Syndikus I, et al. Hypofractionated radiotherapy versus conventionally fractionated radiotherapy for patients with intermediate-risk localised prostate cancer: 2-year patient-reported outcomes of the randomised, non-inferiority, phase 3 CHHiP trial. Lancet Oncol. 2015;16(16):1605-1616. doi:10.1016/S1470-2045(15)00280-6

15. Incrocci L, Wortel RC, Alemayehu WG, et al. Hypofractionated versus conventionally fractionated radiotherapy for patients with localised prostate cancer (HYPRO): final efficacy results from a randomised, multicentre, open-label, phase 3 trial. Lancet Oncol. 2016;17(8):1061-1069. doi.10.1016/S1470-2045(16)30070-5

16. Arcangeli G, Saracino B, Arcangeli S, et al. Moderate hypofractionation in high-risk, organ-confined prostate cancer: final results of a phase III randomized trial. J Clin Oncol. 2017;35(17):1891-1897. doi:10.1200/JCO.2016.70.4189

17. Aluwini S, Pos F, Schimmel E, et al. Hypofractionated versus conventionally fractionated radiotherapy for patients with prostate cancer (HYPRO): late toxicity results from a randomised, non-inferiority, phase 3 trial. Lancet Oncol. 2016;17(4):464-474. doi:10.1016/S1470-2045(15)00567-7

18. Pervez N, Small C, MacKenzie M, et al. Acute toxicity in high-risk prostate cancer patients treated with androgen suppression and hypofractionated intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys. 2010;76(1):57-64. doi:10.1016/j.ijrobp.2009.01.048

19. Magli A, Moretti E, Tullio A, Giannarini G. Hypofractionated simultaneous integrated boost (IMRT- cancer: results of a prospective phase II trial SIB) with pelvic nodal irradiation and concurrent androgen deprivation therapy for high-risk prostate cancer: results of a prospective phase II trial. Prostate Cancer Prostatic Dis. 2018;21(2):269-276. doi:10.1038/s41391-018-0034-0

20. Di Muzio NG, Fodor A, Noris Chiorda B, et al. Moderate hypofractionation with simultaneous integrated boost in prostate cancer: long-term results of a phase I–II study. Clin Oncol (R Coll Radiol). 2016;28(8):490-500. doi:10.1016/j.clon.2016.02.005

21. DeSantis CE, Miller KD, Goding Sauer A, Jemal A, Siegel RL. Cancer statistics for African Americans, 2019. CA Cancer J Clin. 2019;69(3):21-233. doi:10.3322/caac.21555

22. Wolf MS, Knight SJ, Lyons EA, et al. Literacy, race, and PSA level among low-income men newly diagnosed with prostate cancer. Urology. 2006(1);68:89-93. doi:10.1016/j.urology.2006.01.064

23. Rebbeck TR. Prostate cancer disparities by race and ethnicity: from nucleotide to neighborhood. Cold Spring Harb Perspect Med. 2018;8(9):a030387. doi:10.1101/cshperspect.a030387

24. Guidry JJ, Aday LA, Zhang D, Winn RJ. Transportation as a barrier to cancer treatment. Cancer Pract. 1997;5(6):361-366.

25. Friedman DB, Corwin SJ, Dominick GM, Rose ID. African American men’s understanding and perceptions about prostate cancer: why multiple dimensions of health literacy are important in cancer communication. J Community Health. 2009;34(5):449-460. doi:10.1007/s10900-009-9167-3

26. Connell PP, Ignacio L, Haraf D, et al. Equivalent racial outcome after conformal radiotherapy for prostate cancer: a single departmental experience. J Clin Oncol. 2001;19(1):54-61. doi:10.1200/JCO.2001.19.1.54

27. Dess RT, Hartman HE, Mahal BA, et al. Association of black race with prostate cancer-specific and other-cause mortality. JAMA Oncol. 2019;5(1):975-983. doi:10.1200/JCO.2001.19.1.54

28. McKay RR, Sarkar RR, Kumar A, et al. Outcomes of Black men with prostate cancer treated with radiation therapy in the Veterans Health Administration. Cancer. 2021;127(3):403-411. doi:10.1002/cncr.33224

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30. Roach M 3rd, Hanks G, Thames H Jr, et al. Defining biochemical failure following radiotherapy with or without hormonal therapy in men with clinically localized prostate cancer: recommendations of the RTOG-ASTRO Phoenix Consensus Conference. Int J Radiat Oncol Biol Phys. 2006;65(4):965-974. doi:10.1016/j.ijrobp.2006.04.029

31. Freeman VL, Durazo-Arvizu R, Arozullah AM, Keys LC. Determinants of mortality following a diagnosis of prostate cancer in Veterans Affairs and private sector health care systems. Am J Public Health. 2003;93(100):1706-1712. doi:10.2105/ajph.93.10.1706

32. Ward E, Jemal A, Cokkinides V, et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin. 2004;54(2):78-93. doi:10.3322/canjclin.54.2.78

33. Zemplenyi AT, Kaló Z, Kovacs G, et al. Cost-effectiveness analysis of intensity-modulated radiation therapy with normal and hypofractionated schemes for the treatment of localised prostate cancer. Eur J Cancer Care. 2018;27(1):e12430. doi:10.1111/ecc.12430

34. Klabunde CN, Potosky AL, Harlan LC, Kramer BS. Trends and black/white differences in treatment for nonmetastatic prostate cancer. Med Care. 1998;36(9):1337-1348. doi:10.1097/00005650-199809000-00006

35. Harlan L, Brawley O, Pommerenke F, Wali P, Kramer B. Geographic, age, and racial variation in the treatment of local/regional carcinoma of the prostate. J Clin Oncol. 1995;13(1):93-100. doi:10.1200/JCO.1995.13.1.93

36. Riviere P, Luterstein E, Kumar A, et al. Racial equity among African-American and non-Hispanic white men diagnosed with prostate cancer in the veterans affairs healthcare system. Int J Radiat Oncol Biol Phys. 2019;105:E305.

37. Peterson K, Anderson J, Boundy E, Ferguson L, McCleery E, Waldrip K. Mortality disparities in racial/ethnic minority groups in the Veterans Health Administration: an evidence review and map. Am J Public Health. 2018;108(3):e1-e11. doi:10.2105/AJPH.2017.304246

38. Zietman AL, DeSilvio ML, Slater JD, et al. Comparison of conventional-dose vs high-dose conformal radiation therapy in clinically localized adenocarcinoma of the prostate: a randomized controlled trial. JAMA. 2005;294(10):1233-1239. doi:10.1001/jama.294.10.1233

39. Hagan M, Kapoor R, Michalski J, et al. VA-Radiation Oncology Quality Surveillance program. Int J Radiat Oncol Biol Phys. 2020;106(3):639-647. doi.10.1016/j.ijrobp.2019.08.064

40. Carpenter DJ, Natesan D, Floyd W, et al. Long-term experience in an equal access health care system using moderately hypofractionated radiotherapy for high risk prostate cancer in a predominately African American population with unfavorable disease. Int J Radiat Oncol Biol Phys. 2020;108(3):E417. https://www.redjournal.org/article/S0360-3016(20)33923-7/fulltext

Results

We identified 143 patients with HRPC treated with definitive MHRT between November 2008 and August 2018 (Table 1). Mean age was 65 years (range, 36-80 years); 57% were African American men. Eighty percent of individuals had unfavorable high-risk disease. Median (IQR) PSA was 14.4 (7.8-28.6). Twenty-six percent had grade group 1-3 disease, 47% had grade group 4 disease, and 27% had grade group 5 disease. African American patients had significantly lower pre-MHRT IPSS scores than White patients (mean IPSS, 11 vs 14, respectively; P = .02) despite similar rates of preradiotherapy urinary medication usage (66% and 66%, respectively).

Eighty-six percent received 70 Gy over 28 fractions, with institutional protocol shifting to 60 Gy over 20 fractions (14%) in June 2017. The median (IQR) duration of radiotherapy was 39 (38-42) days, with 97% of individuals undergoing ADT for a median (IQR) duration of 24 (24-36) months. The median follow-up time was 38 months, with 57 (40%) patients followed for at least 60 months.

Grade 3 GI and GU acute toxicity events were observed in 1% and 4% of all individuals, respectively (Table 2). No acute GI or GU grade 4+ events were observed. No significant differences in acute GU or GI toxicity were observed between African American and White patients.

No significant differences between African American and White patients were observed for late grade 2+ GI (P = .19) or GU (P = .55) toxicity. Late grade 2+ GI toxicity was observed in 17 (12%) patients overall (Figure 1A). One grade 3 and 1 grade 4 late GI event were observed following MHRT completion: The latter involved hospitalization for bleeding secondary to radiation proctitis in the context of cirrhosis predating MHRT. Late grade 2+ GU toxicity was observed in 80 (56%) patients, with late grade 2 events steadily increasing over time (Figure 1B). Nine late grade 3 GU toxicity events were observed at a median of 13 months following completion of MHRT, 2 of which occurred more than 24 months after MHRT completion. No late grade 4 or 5 GU events were observed. IPSS values both before MHRT and at time of last follow-up were available for 65 (40%) patients, with a median (IQR) IPSS of 10 (6-16) before MHRT and 12 (8-16) at last follow-up at a median (IQR) interval of 36 months (26-76) from radiation completion.

No significant differences were observed between African American and White patients with respect to BRFS, DMFS, PCSS, or OS (Figure 2). Overall, 21 of 143 (15%) patients experienced biochemical recurrence: 5-year BRFS was 77% (95% CI, 67%-85%) for all patients, 83% (95% CI, 70%-91%) for African American patients, and 71% (95% CI, 53%-82%) for White patients. Five-year DMFS was 87% (95% CI, 77%-92%) for all individuals, 91% (95% CI, 80%-96%) for African American patients, and 81% (95% CI, 62%-91%) for White patients. Five-year PCSS was 89% (95% CI, 80%-94%) for all patients, with 5-year PCSS rates of 90% (95% CI, 79%-95%) for African American patients and 87% (95% CI, 70%-95%) for White patients. Five-year OS was 75% overall (95% CI, 64%-82%), with 5-year OS rates of 73% (95% CI, 58%-83%) for African American patients and 77% (95% CI, 60%-87%) for White patients.

Discussion

In this study, we reported acute and late GI and GU toxicity rates as well as clinical outcomes for a majority African American population with predominately unfavorable HRPC treated with MHRT in an equal access health care environment. We found that MHRT was well tolerated with high rates of biochemical control, PCSS, and OS. Additionally, outcomes were not significantly different across patient race. To our knowledge, this is the first report of MHRT for HRPC in a majority African American population.

We found that MHRT was an effective treatment for patients with HRPC, in particular those with unfavorable high-risk disease. While prior prospective and randomized studies have investigated the use of MHRT, our series was larger than most and had a predominately unfavorable high-risk population.^12,15-17Our biochemical and PCSS rates compare favorably with those of HRPC trial populations, particularly given the high proportion of unfavorable high-risk disease.^12,15,16 Despite similar rates of biochemical control, OS was lower in the present cohort than in HRPC trial populations, even with a younger median age at diagnosis. The similarly high rates of non–HRPC-related death across race may reflect differences in baseline comorbidities compared with trial populations as well as reported differences between individuals in the VA and the private sector.³¹ This suggests that MHRT can be an effective treatment for patients with unfavorable HRPC.

We did not find any differences in outcomes between African American and White individuals with HRPC treated with MHRT. Furthermore, our study demonstrates long-term rates of BRFS and PCSS in a majority African American population with predominately unfavorable HRPC that are comparable with those of prior randomized MHRT studies in high-risk, predominately White populations.^12,15,16 Prior reports have found that African American men with HRPC may be at increased risk for inferior clinical outcomes due to a number of socioeconomic, biologic, and cultural mediators.^26,27,32 Such individuals may disproportionally benefit from shorter treatment courses that improve access to radiotherapy, a well-documented disparity for African American men with localized prostate cancer.^33-36 The VA is an ideal system for studying racial disparities within prostate cancer, as accessibility of mental health and transportation services, income, and insurance status are not barriers to preventative or acute care.³⁷ Our results are concordant with those previously seen for African American patients with prostate cancer seen in the VA, which similarly demonstrate equal outcomes with those of other races.^28,36 Incorporation of the earlier mentioned VA services into oncologic care across other health care systems could better characterize determinants of racial disparities in prostate cancer, including the prognostic significance of shortening treatment duration and number of patient visits via MHRT.

References

1. Stokes WA, Kavanagh BD, Raben D, Pugh TJ. Implementation of hypofractionated prostate radiation therapy in the United States: a National Cancer Database analysis. Pract Radiat Oncol. 2017;7:270-278. doi:10.1016/j.prro.2017.03.011

2. Jaworski L, Dominello MM, Heimburger DK, et al. Contemporary practice patterns for intact and post-operative prostate cancer: results from a statewide collaborative. Int J Radiat Oncol Biol Phys. 2019;105(1):E282. doi:10.1016/j.ijrobp.2019.06.1915

3. Miralbell R, Roberts SA, Zubizarreta E, Hendry JH. Dose-fractionation sensitivity of prostate cancer deduced from radiotherapy outcomes of 5,969 patients in seven international institutional datasets: α/β = 1.4 (0.9-2.2) Gy. Int J Radiat Oncol Biol Phys. 2012;82(1):e17-e24. doi:10.1016/j.ijrobp.2010.10.075

4. Tree AC, Khoo VS, van As NJ, Partridge M. Is biochemical relapse-free survival after profoundly hypofractionated radiotherapy consistent with current radiobiological models? Clin Oncol (R Coll Radiol). 2014;26(4):216-229. doi:10.1016/j.clon.2014.01.008

5. Brenner DJ. Fractionation and late rectal toxicity. Int J Radiat Oncol Biol Phys. 2004;60(4):1013-1015. doi:10.1016/j.ijrobp.2004.04.014

6. Tucker SL, Thames HD, Michalski JM, et al. Estimation of α/β for late rectal toxicity based on RTOG 94-06. Int J Radiat Oncol Biol Phys. 2011;81(2):600-605. doi:10.1016/j.ijrobp.2010.11.080

7. Dasu A, Toma-Dasu I. Prostate alpha/beta revisited—an analysis of clinical results from 14 168 patients. Acta Oncol. 2012;51(8):963-974. doi:10.3109/0284186X.2012.719635 start

8. Proust-Lima C, Taylor JMG, Sécher S, et al. Confirmation of a Low α/β ratio for prostate cancer treated by external beam radiation therapy alone using a post-treatment repeated-measures model for PSA dynamics. Int J Radiat Oncol Biol Phys. 2011;79(1):195-201. doi:10.1016/j.ijrobp.2009.10.008

9. Lee WR, Dignam JJ, Amin MB, et al. Randomized phase III noninferiority study comparing two radiotherapy fractionation schedules in patients with low-risk prostate cancer. J Clin Oncol. 2016;34(20): 2325-2332. doi:10.1200/JCO.2016.67.0448

10. Dearnaley D, Syndikus I, Mossop H, et al. Conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer: 5-year outcomes of the randomised, non-inferiority, phase 3 CHHiP trial. Lancet Oncol. 2016;17(8):1047-1060. doi:10.1016/S1470-2045(16)30102-4

11. Catton CN, Lukka H, Gu C-S, et al. Randomized trial of a hypofractionated radiation regimen for the treatment of localized prostate cancer. J Clin Oncol. 2017;35(17):1884-1890. doi:10.1200/JCO.2016.71.7397

12. Pollack A, Walker G, Horwitz EM, et al. Randomized trial of hypofractionated external-beam radiotherapy for prostate cancer. J Clin Oncol. 2013;31(31):3860-3868. doi:10.1200/JCO.2013.51.1972

13. Hoffman KE, Voong KR, Levy LB, et al. Randomized trial of hypofractionated, dose-escalated, intensity-modulated radiation therapy (IMRT) versus conventionally fractionated IMRT for localized prostate cancer. J Clin Oncol. 2018;36(29):2943-2949. doi:10.1200/JCO.2018.77.9868

14. Wilkins A, Mossop H, Syndikus I, et al. Hypofractionated radiotherapy versus conventionally fractionated radiotherapy for patients with intermediate-risk localised prostate cancer: 2-year patient-reported outcomes of the randomised, non-inferiority, phase 3 CHHiP trial. Lancet Oncol. 2015;16(16):1605-1616. doi:10.1016/S1470-2045(15)00280-6

15. Incrocci L, Wortel RC, Alemayehu WG, et al. Hypofractionated versus conventionally fractionated radiotherapy for patients with localised prostate cancer (HYPRO): final efficacy results from a randomised, multicentre, open-label, phase 3 trial. Lancet Oncol. 2016;17(8):1061-1069. doi.10.1016/S1470-2045(16)30070-5

16. Arcangeli G, Saracino B, Arcangeli S, et al. Moderate hypofractionation in high-risk, organ-confined prostate cancer: final results of a phase III randomized trial. J Clin Oncol. 2017;35(17):1891-1897. doi:10.1200/JCO.2016.70.4189

17. Aluwini S, Pos F, Schimmel E, et al. Hypofractionated versus conventionally fractionated radiotherapy for patients with prostate cancer (HYPRO): late toxicity results from a randomised, non-inferiority, phase 3 trial. Lancet Oncol. 2016;17(4):464-474. doi:10.1016/S1470-2045(15)00567-7

18. Pervez N, Small C, MacKenzie M, et al. Acute toxicity in high-risk prostate cancer patients treated with androgen suppression and hypofractionated intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys. 2010;76(1):57-64. doi:10.1016/j.ijrobp.2009.01.048

19. Magli A, Moretti E, Tullio A, Giannarini G. Hypofractionated simultaneous integrated boost (IMRT- cancer: results of a prospective phase II trial SIB) with pelvic nodal irradiation and concurrent androgen deprivation therapy for high-risk prostate cancer: results of a prospective phase II trial. Prostate Cancer Prostatic Dis. 2018;21(2):269-276. doi:10.1038/s41391-018-0034-0

20. Di Muzio NG, Fodor A, Noris Chiorda B, et al. Moderate hypofractionation with simultaneous integrated boost in prostate cancer: long-term results of a phase I–II study. Clin Oncol (R Coll Radiol). 2016;28(8):490-500. doi:10.1016/j.clon.2016.02.005

21. DeSantis CE, Miller KD, Goding Sauer A, Jemal A, Siegel RL. Cancer statistics for African Americans, 2019. CA Cancer J Clin. 2019;69(3):21-233. doi:10.3322/caac.21555

22. Wolf MS, Knight SJ, Lyons EA, et al. Literacy, race, and PSA level among low-income men newly diagnosed with prostate cancer. Urology. 2006(1);68:89-93. doi:10.1016/j.urology.2006.01.064

23. Rebbeck TR. Prostate cancer disparities by race and ethnicity: from nucleotide to neighborhood. Cold Spring Harb Perspect Med. 2018;8(9):a030387. doi:10.1101/cshperspect.a030387

24. Guidry JJ, Aday LA, Zhang D, Winn RJ. Transportation as a barrier to cancer treatment. Cancer Pract. 1997;5(6):361-366.

25. Friedman DB, Corwin SJ, Dominick GM, Rose ID. African American men’s understanding and perceptions about prostate cancer: why multiple dimensions of health literacy are important in cancer communication. J Community Health. 2009;34(5):449-460. doi:10.1007/s10900-009-9167-3

26. Connell PP, Ignacio L, Haraf D, et al. Equivalent racial outcome after conformal radiotherapy for prostate cancer: a single departmental experience. J Clin Oncol. 2001;19(1):54-61. doi:10.1200/JCO.2001.19.1.54

27. Dess RT, Hartman HE, Mahal BA, et al. Association of black race with prostate cancer-specific and other-cause mortality. JAMA Oncol. 2019;5(1):975-983. doi:10.1200/JCO.2001.19.1.54

28. McKay RR, Sarkar RR, Kumar A, et al. Outcomes of Black men with prostate cancer treated with radiation therapy in the Veterans Health Administration. Cancer. 2021;127(3):403-411. doi:10.1002/cncr.33224

29. Muralidhar V, Chen M-H, Reznor G, et al. Definition and validation of “favorable high-risk prostate cancer”: implications for personalizing treatment of radiation-managed patients. Int J Radiat Oncol Biol Phys. 2015;93(4):828-835. doi:10.1016/j.ijrobp.2015.07.2281

30. Roach M 3rd, Hanks G, Thames H Jr, et al. Defining biochemical failure following radiotherapy with or without hormonal therapy in men with clinically localized prostate cancer: recommendations of the RTOG-ASTRO Phoenix Consensus Conference. Int J Radiat Oncol Biol Phys. 2006;65(4):965-974. doi:10.1016/j.ijrobp.2006.04.029

31. Freeman VL, Durazo-Arvizu R, Arozullah AM, Keys LC. Determinants of mortality following a diagnosis of prostate cancer in Veterans Affairs and private sector health care systems. Am J Public Health. 2003;93(100):1706-1712. doi:10.2105/ajph.93.10.1706

32. Ward E, Jemal A, Cokkinides V, et al. Cancer disparities by race/ethnicity and socioeconomic status. CA Cancer J Clin. 2004;54(2):78-93. doi:10.3322/canjclin.54.2.78

33. Zemplenyi AT, Kaló Z, Kovacs G, et al. Cost-effectiveness analysis of intensity-modulated radiation therapy with normal and hypofractionated schemes for the treatment of localised prostate cancer. Eur J Cancer Care. 2018;27(1):e12430. doi:10.1111/ecc.12430

34. Klabunde CN, Potosky AL, Harlan LC, Kramer BS. Trends and black/white differences in treatment for nonmetastatic prostate cancer. Med Care. 1998;36(9):1337-1348. doi:10.1097/00005650-199809000-00006

35. Harlan L, Brawley O, Pommerenke F, Wali P, Kramer B. Geographic, age, and racial variation in the treatment of local/regional carcinoma of the prostate. J Clin Oncol. 1995;13(1):93-100. doi:10.1200/JCO.1995.13.1.93

36. Riviere P, Luterstein E, Kumar A, et al. Racial equity among African-American and non-Hispanic white men diagnosed with prostate cancer in the veterans affairs healthcare system. Int J Radiat Oncol Biol Phys. 2019;105:E305.

37. Peterson K, Anderson J, Boundy E, Ferguson L, McCleery E, Waldrip K. Mortality disparities in racial/ethnic minority groups in the Veterans Health Administration: an evidence review and map. Am J Public Health. 2018;108(3):e1-e11. doi:10.2105/AJPH.2017.304246

38. Zietman AL, DeSilvio ML, Slater JD, et al. Comparison of conventional-dose vs high-dose conformal radiation therapy in clinically localized adenocarcinoma of the prostate: a randomized controlled trial. JAMA. 2005;294(10):1233-1239. doi:10.1001/jama.294.10.1233

39. Hagan M, Kapoor R, Michalski J, et al. VA-Radiation Oncology Quality Surveillance program. Int J Radiat Oncol Biol Phys. 2020;106(3):639-647. doi.10.1016/j.ijrobp.2019.08.064

40. Carpenter DJ, Natesan D, Floyd W, et al. Long-term experience in an equal access health care system using moderately hypofractionated radiotherapy for high risk prostate cancer in a predominately African American population with unfavorable disease. Int J Radiat Oncol Biol Phys. 2020;108(3):E417. https://www.redjournal.org/article/S0360-3016(20)33923-7/fulltext

Marital status plays modest role in gastric cancer overall survival

Impact of Race on Outcomes of High-Risk Patients With Prostate Cancer Treated With Moderately Hypofractionated Radiotherapy in an Equal Access Setting

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Impact of Race on Outcomes of High-Risk Patients With Prostate Cancer Treated With Moderately Hypofractionated Radiotherapy in an Equal Access Setting

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