Date of Award

January 2023

Document Type


Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Michael Leapman


Although definitive treatment is associated with improved survival for aggressive prostate cancer and is supported by clinical practice guidelines, a significant number of patients do not receive definitive treatment. To identify gaps in practice, we sought to evaluate sociodemographic factors associated with treatment of localized prostate cancer across clinically relevant risk strata. We performed a retrospective study of patients with prostate cancer using the National Cancer Database. A total of 954,591 patients diagnosed with localized prostate (cT1-4N0M0) cancer from 2010 to 2020 were included in the analysis. We used descriptive statistics and multivariable logistic regression to evaluate factors associated with non-treatment, stratifying analyses by D’Amico clinical risk criteria. The mean patient age at diagnosis was 65 years. Overall, 26.0% were diagnosed with low, 43.4% with intermediate, and 30.6% with high-risk prostate cancer. There were 131,122 (13.7%) who did not undergo initial treatment, including 82,318 (62.8%) with low, 35,499 (27.1%) with intermediate, and 13,305 (10.2%) with high-risk disease. The proportion of patients not receiving treatment increased over time in all risk groups between 2010 and 2010, including among low (11.7% versus 59.5%), intermediate (4.5% versus 12.5%) and high risk (3.6% versus 5.1%) disease. Compared with White patients, Black patients had lower odds of definitive treatment. This effect was more pronounced for patients with high (OR 0.61, 95% CI 0.58-0.64) rather than intermediate (OR 0.76, 95% CI 0.73-0.78) and low (OR 0.88, 95% CI 0.77-1.00) risk prostate cancer. Asian patients had lower odds of treatment compared with White patients across all disease risk strata (OR 0.84, 95% CI 0.80-0.88). There were lower odds of treatment among American Native/Alaskan Native versus White patients (OR 0.88, 95% CI 0.77-1.00). Uninsured (OR 0.45, 95% CI 0.42-0.47), and Medicaid-insured (OR 0.68, 95% CI 0.66-0.71, p<0.001) patients were less likely to be treated. Patients residing in higher income areas had lower odds of definitive treatment for low-risk prostate cancer (OR 0.84, 95% CI 0.81-0.87) and higher odds of treatment for high-risk prostate cancer (OR 1.34, 95% CI 1.25-1.44) compared to those in the lowest income quartile, suggesting a potentially higher rate of guideline-concordant care. Among patients diagnosed with prostate cancer in the contemporary era, Black race, Medicaid insurance, no insurance, and low income are associated with non-treatment for aggressive prostate cancer.


This thesis is restricted to Yale network users only. It will be made publicly available on 05/10/2024