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. Author manuscript; available in PMC: 2020 Sep 2.
Published in final edited form as: Cancer. 2019 Jun 27;125(19):3418–3427. doi: 10.1002/cncr.32338

Prevalence and Predictors of Probable Depression in Prostate Cancer Survivors

Daniel O Erim 1,2, Jeannette T Bensen 3,4, James L Mohler 5, Elizabeth T H Fontham 6, Lixin Song 4,7, Laura Farnan 4, Scott E Delacroix 8, Edward S Peters 6, Theodora N Erim, Ronald C Chen 4,9, Bradley N Gaynes 10
PMCID: PMC7465428  NIHMSID: NIHMS1618657  PMID: 31246284

Abstract

BACKGROUND:

The early diagnosis and treatment of depression are cancer care priorities. These priorities are critical for prostate cancer survivors because men rarely seek mental health care. However, little is known about the epidemiology of depression in this patient population. The goal of this study was to describe the prevalence and predictors of probable depression in prostate cancer survivors.

METHODS:

The data were from a population-based cohort of North Carolinian prostate cancer survivors who were enrolled from 2004 to 2007 in the North Carolina-Louisiana Prostate Cancer Project (n = 1031) and were prospectively followed annually from 2008 to 2011 in the Health Care Access and Prostate Cancer Treatment in North Carolina study (n = 805). Generalized estimating equations were used to evaluate an indicator of probable depression (Short Form 12 mental composite score ≤48.9; measured at enrollment and during the annual follow-up) as a function of individual-level characteristics within the longitudinal data set.

RESULTS:

The prevalence of probable depression fell from 38% in the year of the cancer diagnosis to 20% 6 to 7 years later. Risk factors for probable depression throughout the study were African American race, unemployment, low annual income, younger age, recency of cancer diagnosis, past depression, comorbidities, treatment decisional regret, and nonadherence to exercise recommendations.

CONCLUSIONS:

Depression is a major challenge for prostate cancer survivors, particularly in the first 5 years after the cancer diagnosis. To the authors’ knowledge, this is the first study to demonstrate an association between treatment decisional regret and probable depression.

Keywords: depression, health disparity, predictors, prostate cancer, risk factors

INTRODUCTION

The prevalence of common depressive disorders (major and persistent depressive disorders or depression) is up to 25% in cancer survivors (vs 5%-6% in noncancer controls).1,2 The causal pathway between cancer and depression remains unclear, but plausible explanations include biological factors (eg, cancer cells producing depression-inducing chemicals),3 psychological factors (eg, the trauma of a cancer diagnosis),4,5 environmental factors (eg, a side effect of chemotherapy),6 and behavioral factors (eg, depression hindering self-care abilities).7,8 Regardless of the causal mechanism, an elevated risk for depression persists at all times after a cancer diagnosis.9,10

Depression adversely affects the cost, quality, and duration of survivorship; hence, primary prevention and secondary prevention of depression are cancer care priorities. Prevention of depression is a cancer care priority because of the adverse effect that depression has on the cost, quality, and duration of survivorship.11–16 These priorities are critical to prostate cancer survivors because men are usually reluctant to report depressive symptoms or seek mental health care,17–19 and depression has been linked to certain prostate cancer treatment types (eg, androgen deprivation therapy) and complications (eg, erectile dysfunction).20,21 Approximately 750,000 prostate cancer survivors in the United States are depressed.22–24 However, little is known about the epidemiology of depression in this patient population. The goal of this study was to describe the prevalence and predictors of probable depression in prostate cancer survivors (we use the word probable because of our identifying strategy; more details are given later). The study was designed to motivate/support depression care recommendations in survivorship guidelines.22

The analytic approach was informed by Kinser and Lyon’s conceptual model for individual stress vulnerability, depression, and health outcomes.25 The authors of the conceptual model suggested that sociodemographic characteristics (eg, race, unemployment, and low income),26–32 lifestyle factors (eg, a lack of exercise),33,34 acute and chronic burdens (eg, treatment decisional regret), and interpersonal situations affect a person’s susceptibility to stress vulnerabilities that often precede depression.25 After reviewing evidence on stress vulnerabilities in other patient populations, we hypothesized that sociodemographic characteristics such as age, African American race, low education, rural residence, being unmarried, unemployment, and low income were positively associated with probable depression.22,26

MATERIALS AND METHODS

Study Population and Procedure

Panel data from a population-based cohort of North Carolinian prostate cancer survivors who were enrolled from 2004 to 2007 in the North Carolina–Louisiana Prostate Cancer Project (PCaP) were assessed (n = 1031).35,36 In brief, PCaP is a study of environmental, biological, and behavioral causes of racial differences in prostate cancer aggressiveness.36 North Carolinian participants received a prostate cancer diagnosis on or after July 1, 2004; they were identified with records from the North Carolina Central Cancer Registry. African American and white American survivors were enrolled in equal proportions (the sampling weight was 1:0.44, respectively).36 North Carolinian participants were enrolled between September 2004 and December 2007, and they provided questionnaire data, biological specimens, and permission to obtain medical records. Participants also had up to 3 annual follow-up interviews in the Health Care Access and Prostate Cancer Treatment in North Carolina (HCaP-NC) study (2008-2011; n = 805). Interview questionnaires were completed by regular mail or by phone interview during annual follow-up contacts (ie, September 2008 to August 2009 [first wave], September 2009 to August 2010 [second wave], and September 2010 to August 2011 [third wave]). Data from 1024 participants were analyzed, and this study was approved by the Office of Human Research Ethics of the University of North Carolina at Chapel Hill (study #17-0183).

Measures

Identifying probable depression

Short Form 12 (SF-12) is a validated 12-item self-reported questionnaire that measures generic health-related quality of life.37 SF-12 item response choices are on either a Likert or binary (yes/no) scale, and responses are scored, weighed, and summed to yield physical composite scores and mental composite scores (MCSs). Composite scores range from 0 to 100 (with higher scores indicating better health) and provide insight into physical and mental health aspects of health-related quality of life. The SF-12 MCS can be used to identify depressed adults in population studies.38–40 The credibility of this approach results from the SF-12 MCS’s high negative correlation with depression severity and SF-12 items that refer to symptoms in the diagnostic criteria for depression (eg, depressed mood).41–43 Vilagut et al38 have shown that an SF-12 MCS threshold score of 48.9 is 74% sensitive and 83% specific for depression occurring in the prior 12 months. The threshold score of 48.9 was used to create a binary indicator of probable depression for each participant at enrollment and during the 3 indicated annual follow-up contacts. The term probable depression is used throughout this text because the indicated SF-12 MCS threshold score is nondiagnostic.

Predictors

The key explanatory variables were age at enrollment, race, educational attainment (up to high school or beyond high school), rural or urban residence (according to the 2010 US Census classification),44 index marital status (currently married, previously married, or never married), index employment status (retired, employed, or unemployed), and index annual income (≤$20,000, $20,001-$40,000, $40,001-$70,000, or >$70,000). Control covariates included the time since the prostate cancer diagnosis (in years) as well as binary indicators of the following: prostate cancer stage at diagnosis (T1 vs T2/T3; see Table 1), self-reported clinical diagnosis of depression before enrollment, probable depression in any prior survey wave, Charlson Comorbidity Index score (0-1 vs ≥ 2),45 availability of social/emotional support at each survey contact, index tobacco use, index alcohol use, adherence to the exercise recommendations of the World Health Organization (WHO; ie, at least 600 metabolic equivalent minutes per week) in the 12 months preceding survey contact,46 and treatment decisional regret during follow-up (measured with Clark et al’s 2001 regret scale47 [specific to prostate cancer survivors], which is different from O’Connor et al’s 1996 decision regret scale48 [not specific to prostate cancer survivors]).

TABLE 1.

Baseline Characteristics of the Study Participants (n = 1024)

Characteristic No. (%) Characteristic No. (%)
Sample size 1024 (100) Age at enrollment
 40-49 y 51 (5)
Probable depression at enrollment  50-59 y 322 (31)
 No 715 (70)  60-69 y 425 (42)
 Yes 305 (30)  70-79 y 226 (22)
Race Time since prostate cancer diagnosis
 African American 525 (51)  0-12 mo 963 (94)
 White American 499 (49)  13-24 mo 58 (6)
Marital status  25-36 mo 3 (<1)
 Currently married 776 (76) Has health insurance
 Previously married 188 (18)  No 518 (51)
 Never married 59 (6)  Yes 506 (49)
Educational attainment Cancer stage at diagnosisa
 High school or less than high school 490 (48)  T1 609 (60)
 More than high school 533 (52)  T2/T3 408 (40)
Residence Charlson Comorbidity Index
 Urban 781 (76)  0-1 766 (75)
 Rural 243 (24)  ≥2 257 (25)
Employment status Adheres to exercise recommendations
 Retired 480 (47)  No 256 (25)
 Employed/yet to retire 485 (48)  Yes 767 (75)
 Unemployed 56 (5) Current tobacco use
Annual income  No 526 (76)
 >$70,000 311 (32)  Yes 162 (24)
 $40,001 -$70,000 240 (25) Current alcohol use
 $20,001-$40,000 235 (24)  No 407 (40)
 <$20,000 182 (19)  Yes 614 (60)
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a

The cancer stage at diagnosis was based on the size and extent of the primary tumor (see Prostate Cancer: Stages and Grades at https://www.cancer.net/cancer-types/prostate-cancer/stages-and-grades). At stage T1, the tumor is not detectable with a digital rectal examination or imaging but is found in prostate tissue from a biopsy or surgical treatment. At stage T2, the tumor is detectable with a digital rectal examination or imaging but is confined to the prostate. At stage T3, the cancer has grown outside the prostate and may have grown into the seminal vesicles. At stage T4, the cancer has grown into other nearby tissues, such as the urethral sphincter, rectum, bladder, or wall of the pelvis.

Not all groups of n values add up to 1024 due to missing observations.

Treatment decisional regret was assessed with the following 2 questions: whether the participant would have been better off with a different cancer treatment type (possible responses included definitely false, somewhat false, neither true nor false, somewhat true, and definitely true) and the amount of time that the participant spent wishing that he could change his mind about the cancer treatment type (possible responses included none of the time, rarely, neither a little nor a lot of the time, some of the time, and all of the time).47,48 A participant had treatment decisional regret if he definitely or somewhat agreed that he would have been better off choosing a different cancer treatment type or if he spent all or some of the time wishing that he could change his mind about the cancer treatment type.47,48 Treatment decisional regret was not assessed during enrollment. However, it was assumed that there was no regret at enrollment because 1) participants either were awaiting or had recently received cancer treatment and 2) available evidence suggests that treatment decisional regret is negligible in recently treated prostate cancer survivors.49,50 This assumption was examined with sensitivity analyses.

Statistical Analyses

Generalized estimating equations (GEEs) with a binomial family, logit link, and independent correlation (the correlation structure with the least quasi-likelihood under the independence model criterion [QIC]) were used to evaluate an indicator of probable depression as a function of indicated key explanatory variables and control covariates.51,52 The model was used to predict the average and annual prevalence of probable depression in the first 7 years after the cancer diagnosis. Survey sampling weights were applied, and an α value of .05 was used to determine statistical significance. Sensitivity analyses were performed with alternative GEE correlation structures (ie, unstructured and exchangeable) and an alternative assumption about treatment decisional regret during enrollment (ie, all participants had treatment decisional regret).

Dealing with missing data

Approximately 400 participants were lost to follow-up before the end of HCaP-NC (see Fig. 1). Chi-square and t-tests showed that participants lost to follow-up were more likely to be African American, uninsured, smokers, and low-income earners with a higher prostate cancer stage at diagnosis. Logit regression showed that loss to follow-up was random conditional on observed variables.53 Survey response rates were higher than 95% (with respect to analytic variables) during each survey contact. Missing observations from survey nonresponses occurred at random and were handled via multiple imputation (with 50 imputed data sets for explanatory variables only).54–56 Details of the imputation process (including specifications and diagnostics) are provided in the supplement.

Figure 1.

Figure 1.

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Schematic showing how study participation changed over time.

RESULTS

Descriptive Statistics

Baseline characteristics of study participants are presented in Table 1. Most participants were middle-aged or elderly, were urban residents, were previously or currently married, were retired or employed, and were enrolled within the 12 months after their prostate cancer diagnosis. Most participants had early-stage prostate cancer, had Charlson Comorbidity Index scores between 0 and 1, adhered to WHO’s exercise recommendations, and consumed alcoholic beverages but not tobacco-containing products.

Prevalence of Probable Depression

The average prevalence of probable depression was 28% over the study period. This prevalence had a temporal trend (Fig. 2): it was highest in the first 2 years after the cancer diagnosis (approximately 38%) before significantly declining to 20% in the seventh year (P < .01; Table 2).

Figure 2.

Figure 2.

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Temporal trend in the annual predicted prevalence of probable depression in study participants.

TABLE 2.

Factors Associated With Probable Depression

Variable Odds Ratio Marginal Effect Variable Odds Ratio Marginal Effect
Race Educational attainment
 White American (referent) – –  High school or less – –
 African American 1.33a (1.07 to 1.66) 0.05a (0.01 to 0.09)  More than high school 0.95 (0.75 to 1.21) −0.01 (−0.05 to 0.03)
Marital status Residence
 Currently married (referent) – –  Mostly urban (referent) – –
 Previously/never married 1.19 (0.91 to 1.56) 0.03 (−0.02 to 0.08)  Mostly rural 0.88 (0.69 to 1.12) −0.02 (−0.06 to 0.02)
Age at enrollment 0.98a (0.97 to 0.99) −0.003a (−0.01 to −0.001) Has treatment decisional regret
 No (referent) – –
 Yes 3.31b (2.23 to 4.92) 0.23b (0.15 to 0.32)
Received a clinical diagnosis of depression before enrollment Probable depression in any prior survey wave
 No (referent) – –  None (referent) – –
 Yes 2.44b (1.82 to 3.27) 0.17b (0.11 to 0.23)  1 or more 4.37b (3.39 to 5.64) 0.29b (0.24 to 0.34)
Time since cancer diagnosis Employment status
 0-12 mo (referent) – –  Retired (referent) – –
 13-24 mo 0.73 (0.43 to 1.23) −0.06 (−0.15 to 0.04)  Employed/yet to retire 1.28 (1.00 to 1.64) 0.04 (−0.001 to 0.08)
 25-36 mo 0.57a (0.34 to 0.95) −0.10a (−0.19 to −0.01)  Unemployed 1.74b (1.18 to 2.56) 0.10b (0.02 to 0.17)
 37-48 mo 0.44b (0.27 to 0.69) −0.14b (−0.22 to −0.06) Annual income
 $70,000 (referent) – –
 49-60 mo 0.42b (0.26 to 0.67) −0.15b (−0.22 to −0.07)  $40,001-$70,000 1.26 (0.96 to 1.65) 0.04 (−0.01 to 0.08)
 61-72 mo 0.34b (0.20 to 0.58) −0.17b (−0.25 to −0.09)  $20,001-$40,000 1.28 (0.93 to 1.76) 0.04 (−0.01 to 0.09)
 73-84 mo 0.33b (0.16 to 0.66) −0.18b (−0.28 to −0.08)  ≤$20,000 1.57a (1.03 to 2.39) 0.08a (0.002 to 0.15)
Cancer stage at diagnosis Charlson Comorbidity Index
 T1: a-c (referent) – –  0-1 (referent) – –
 T2/T3: a-c 1.03 (0.84 to 1.26) 0.01 (−0.03 to 0.04)  ≥2 1.59b (1.28 to 1.96) 0.08b (0.04 to 0.12)
Has emotional support Adherent to exercise recommendations
 No (referent) – –  No (referent) – –
 Yes 1.11 (0.73 to 1.68) 0.02 (−0.05 to 0.09)  Yes 0.67b (0.55 to 0.82) −0.07b (−0.10 to −0.03)
Current tobacco use Current alcohol use
 No (referent) – –  No (referent) – –
 Yes 1.13 (0.85 to 1.50) 0.02 (−0.03 to 0.07)  Yes 1.07 (0.87 to 1.33) 0.01 (−0.02 to 0.05)
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There were 1024 participants and 3128 participant observations. Ninety-five percent confidence intervals are presented in parentheses. Fifty imputed data sets were used.

a

P ≤ .05.

b

P ≤ .01.

Predictors of Probable Depression

Variables associated with a higher risk of probable depression (ie, risk factors) throughout the study were African American race, unemployment, low income, past depressive episodes, a Charlson Comorbidity Index score of 2 or higher, and treatment decisional regret (Table 2). Variables associated with a lower risk of probable depression (ie, protective factors) throughout the study were age at enrollment, length of prostate cancer survivorship (ie, 3 or more years), and adherence to WHO’s exercise recommendations. No significant association was found between probable depression and any other model covariate.

Sensitivity Analyses

Study findings remained robust in GEEs with alternative correlation structures and under the assumption that all participants had treatment decisional regret during enrollment. Interaction terms (ie, between treatment decisional regret and cancer treatment type and between treatment decisional regret and cancer recurrence) were included as model covariates in separate regression models to examine whether the observed association between probable depression and treatment decisional regret varied by cancer treatment type or cancer recurrence. No significant difference was observed across categories of the interaction terms. In addition, we found no evidence of a significant association between probable depression and prostate cancer treatment type (and, by extension, side effects) or prostate cancer recurrence.

DISCUSSION

Study Implications

Unequal access to mental health care may explain the association between race and probable depression. Evidence from studies in the general population have shown that the incidence of depression is identical in African Americans and white Americans and that African Americans have poorer access to mental health care in comparison with white Americans.28,57–59 Appropriate depression care promotes recovery and prevents relapse/recurrence of depression60,61; thus, limited access to mental health care may make African American prostate cancer survivors more vulnerable to depression. However, little is known about access to mental health care among prostate cancer survivors, and this will be examined in another study.

Up to 2 in 5 participants experienced probable depression in the first 2 years after their cancer diagnosis. This is consistent with findings from studies on patients with other types of cancer and suggests a high need for depression care in recently diagnosed survivors.5,62 In addition, the annual prevalence of probable depression between the fifth and seventh years (ie, 20%; see Fig. 2) is similar to the post–cancer treatment prevalence of depression in the prostate cancer literature (ie, 18%; 95% confidence interval [CI], 15%-22%).23 This finding suggests that the prevalence of depression among prostate cancer survivors remains stable from 5 years after the cancer diagnosis. Moreover, the initial downward trend in the annual prevalence of probable depression may be explained by developing or peaked psychological resilience, which has been shown to protect prostate cancer survivors from depression.63

The association between adherence to WHO’s exercise recommendations and probable depression is consistent with the literature.33,34 The American Cancer Society’s prostate cancer survivorship guideline promotes regular exercise and lists benefits that are expected to improve the survivorship experience (eg, lower risks of prostate cancer recurrence, fatigue, and anxiety). The survivorship guideline recommends regular patient-provider conversations about exercise. However, available evidence suggests that many providers fail to discuss exercise with their patients,64,65 and this inaction among cancer care providers should be discouraged.

The American Cancer Society’s prostate cancer survivorship guideline also encourages providers to screen for depression in survivors at risk for depression. Indicated risk factors include being unmarried, low education, advanced prostate cancer, low physical or cognitive functioning, younger age, medical comorbidities, psychiatric history, and poor coping skills.22 This study presents supportive evidence for some indicated risk factors (ie, young age, medical comorbidities, and psychiatric history). However, other risk factors identified in this study (ie, African American race, unemployment, low annual income, treatment decisional regret, and nonadherence to WHO’s exercise recommendations) should be considered for inclusion in the guideline. An unemployed African American participant who earns less than $20,000 per year, has treatment decisional regret, and is nonadherent to exercise recommendations faces a 70% chance of probable depression (95% CI, 58%-80%) over a 12-month period. However, because of the low depression screening rate among men in the general population (4%-8%)66,67 and the rate of clinical recognition of depression among nonmental health providers (36%-47%),68,69 depression in this hypothetical participant is likely to remain undiagnosed.

Lastly, to the best of our knowledge, this study is the first to demonstrate an association between treatment decisional regret and depression.70 Treatment decisional regret affects 4% to 18% of prostate cancer survivors in the near term,48,71,72 and emerging evidence suggests that its association with depression is due to repetitive negative thinking.73,74 Available evidence also suggests that treatment decisional regret is likely to occur in prostate cancer survivors who assume a passive role in cancer treatment decision making.50,71,75 Hence, preventing future depression may be an additional motivating factor for active participation in cancer treatment decision making.

Strengths and Limitations

This study has several strengths. Several clinically relevant factors (eg, depression history, comorbidities, and cancer stage) were controlled in all regression models. In addition, the application of sampling weights makes study findings generalizable to prostate cancer survivors in North Carolina. However, the generalizability of study findings to all prostate cancer survivors in the United States remains uncertain. The distributions of prostate cancer survivors by age and race during enrollment in the Surveillance, Epidemiology and End Results program (2011-2015) and PCaP (2004-2007) are similar in the 2 data sets (Table 3). Any differences may be driven by the relative sample sizes or an earlier age at cancer diagnosis for PCaP participants.

TABLE 3.

Comparison of Prostate Cancer Survivors During Enrollment in PCaP and in SEER by Race and Age

SEER (2011-2015) PCaP (2004-2007) P
No. of African American enrollees 7604 505 –
Distribution of African
 American enrollees by age, %
  <40 y 0 0 .65
  40-49 y 4 6 .07
  50-59 y 28 39 <.05
  60-69 y 44 37 <.05
  70-79 y 19 18 .58
  ≥80 y 5 0 <.01
No. of white American enrollees 36,208 526
Distribution of white
 American enrollees by age, %
  <40 y 0 0 .47
  40-49 y 2 4 <.05
  50-59 y 18 24 <.05
  60-69 y 42 46 .55
  70-79 y 28 26 .42
  ɥ80 y 10 0 <.05
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Abbreviations: PCaP, North Carolina-Louisiana Prostate Cancer Project; SEER, Surveillance, Epidemiology, and End Results.

P values were estimated with binomial tests of proportions.

The identification strategy for depression (SF-12 MCS ≤48.9) is imperfect (sensitivity, 74%; specificity, 83%). Hence, the false-positives and false-negatives in the data set may bias regression estimates toward the null or increase variances and risks of type II errors in explanatory variables. This risk of a type II error may affect the expected association between employment (vs retirement) and probable depression (odds ratio, 1.28; P = .052; see Table 2).76 However, study findings are likely to remain robust if a diagnostic instrument such as Patient Health Questionnaire 9 is used to identify depressed study participants (sensitivity, 80%; specificity, 92%).77,78

New episodes of probable depression could not be teased apart from recurrence/relapses, nor could anxiety disorders be isolated from probable depression. These limitations preclude accurate measurement of the annual incidence of depression in the sample. Also, the study sample did not include prostate cancer survivors with late-stage cancer, so the study findings do not extend to late-stage disease.

Lastly, the identification strategy for depression prevents the separation of anxiety disorders from probable depression or new cases from recurrences and relapses. These limitations prevent precise measurement of the annual incidence of probable depression among study participants, which could be used to simulate the natural history of depression in hypothetical prostate cancer survivors via Markov/microsimulation models. However, a conservative estimate was derived by the conversion of the 5-year cumulative incidence of probable depression between the third and seventh years after the prostate cancer diagnosis (ie, when the annual prevalence of probable depression appeared stable; see Fig. 2) into an annual incidence with a standard approach (ie, the proportion of incidental true-positive cases [n1 = 154] and incidental false-negative cases [n2 = 62] among at-risk study participants [N = 575] is (n1 + n2)/N or 216/575 or 37.6% over a 5-year period, which translates into 9.0% per year [95% CI, 7.9%-10.2%] under the constant incidence assumption).79,80 This conservative estimate of the annual incidence of probable depression may approximate the true annual incidence of depression because it is approximately 5 times the annual incidence of depression in Canadian men aged 65 years and older (ie, 1.8%),81 approximately 6 to 8 times the annual incidence of depression in Swedish men aged 70 to 85 years (ie, 1.2%),82 and consistent with the cancer literature (depression is up to 6 times more common in patients with cancer in comparison with the general population).1,2 However, the true annual incidence of depression in prostate cancer survivors may be lower than 9.0% because the estimated cumulative incidence may have inadvertently included a few recurrent cases.79 Conversely, the true annual incidence of depression may be higher than 9.0% because study participants who were lost to follow-up had fewer opportunities to be identified as true-positive cases. Nevertheless, 9.0% seems to be a more plausible estimate than 16% to 17%, which was obtained from inpatient samples of prostate cancer survivors with advanced disease.20,83

In conclusion, depression is a major challenge for prostate cancer survivors, particularly in the first 5 years after their cancer diagnosis. Risk factors for depression include African American race, unemployment, low annual income, relatively young age, recency of cancer diagnosis, past depression, comorbidities, treatment decisional regret, and nonadherence to WHO’s exercise recommendations.

Supplementary Material

supplementary tables

Acknowledgments

We thank the staff, advisory committees, and research subjects that participated in the North Carolina–Louisiana Prostate Cancer Project and Health Care Access and Prostate Cancer Treatment in North Carolina studies for their important contributions. We also acknowledge contributions from the following individuals: Sally C. Stearns, PhD, George Pink, PhD, Marisa E. Domino, PhD, Antonia V. Bennet, PhD, Nkechi Conteh, MD, MPH, and Adrian Gerstel.

FUNDING SUPPORT

The North Carolina–Louisiana Prostate Cancer Project and the Health Care Access and Prostate Cancer Treatment in North Carolina study were supported by the Department of Defense (contract DAMD 17-03-2-0052) and the American Cancer Society (award RSGT-08-008-01-CPHPS).

CONFLICT OF INTEREST DISCLOSURES

Ronald C. Chen reports grants and personal fees from Accuray, Inc, and personal fees from Astellas/Medivation, Bayer, Inc, and Blue Earth outside the submitted work. The other authors made no disclosures.

Footnotes

Additional supporting information may be found in the online version of this article.

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