Determinants of treatment intensification in metastatic hormone-sensitive prostate cancer: Institutional vs patient-level factors in a diverse UK multicentre cohort.

Abstract

40 Background: In the United States, racial disparities in the use of treatment intensification (TI) for metastatic hormone-sensitive prostate cancer (mHSPC) have been documented, with Black men less likely to receive intensified therapy. Whether such disparities exist within the UK's National Health Service (NHS), which provides equal access to care, remains unclear. This study represents the first analysis outside the U.S. to evaluate determinants of TI in mHSPC across institutional practice and patient acceptance, within an equal-access healthcare system. Methods: A retrospective cohort study was conducted on all patients with mHSPC and ECOG performance status 0–2 discussed at multidisciplinary team meetings at Barts Health and Homerton NHS Trusts between March 2020 and December 2023. These centers serve one of the UK’s most ethnically and socioeconomically diverse populations; 36% of the cohort identified as Black. Mixed-effects multivariable logistic regression, with prescribing clinician as a random effect, was used to evaluate factors associated with TI offering and acceptance. Survival outcomes were assessed using Kaplan-Meier, Cox regression, and restricted mean survival time (RMST) analysis. Results: Among 173 eligible patients, TI was offered to 87% (151/173), with 79% (117/151) accepting—equating to 68% of the total cohort receiving TI. Ethnicity did not influence whether TI was offered. Older age was the only independent predictor of not offering TI (OR 0.87 per year; 95% CI 0.81–0.93; p<0.001), with minimal variation between clinicians (ICC 0.011). However, TI acceptance was significantly lower among Black men (OR 0.20; 95% CI 0.07–0.56; p<0.001), older patients (OR 0.90; 95% CI 0.85–0.95; p<0.001), and those with ECOG 2 (OR 0.27; 95% CI 0.10–0.77; p=0.01). Socioeconomic deprivation and comorbidities did not influence TI decisions. At five years, median overall survival was not reached; RMST was 52.1 months. Low disease volume was associated with improved survival (HR 0.27; 95% CI 0.10–0.71), while ethnicity had no effect on survival (HR 0.87; 95% CI 0.47–1.61; p=0.66). Conclusions: In this ethnically diverse NHS cohort with equal healthcare access, no evidence of institutional or physician bias was found in offering TI. However, Black men were less likely to accept TI when offered. These findings highlight the importance of culturally sensitive, shared decision-making to improve equity in mHSPC treatment uptake and outcomes.