Geographic disparities and temporal trends in aggressive prostate cancer: a SEER population-based analysis (2004–2022)

PURPOSE: Prostate cancer burden may be amplified in rural regions or Appalachia areas, where access to screening and healthcare may be limited. This study examined geographic disparities and temporal trends in aggressive and metastatic prostate cancer across four groups defined by rurality and Appalachian status, while assessing assessed racial differences. METHODS: We conducted a retrospective study using the Surveillance, Epidemiology, and End Results (SEER) including newly diagnosed prostate cancer men aged ≥40 years (2004-2022). Age-adjusted incidences of more aggressive and metastatic cases were estimated for each geographical region. Multivariable logistic regression was used to evaluate geographic and racial disparities in risk of more aggressive cases, adjusting for demographic and clinical factors. RESULTS: We identified 951,965 eligible cases. Overall prostate cancer incidence declined in most regions, with a decrease in rural Appalachia (Annual percent changes [APC] = - 1.7%; 95% CI: [- 2.98%, - 0.42%]). Incidence of more aggressive cases increased over time particularly in urban Appalachia (APC = 2.73%; 95% CI: [1.20%, 4.65%]). For metastatic cases, urban Appalachia had the lowest overall incidence and rural non-Appalachia the highest, and rates increased across regions after 2020. In multivariable regression, geographic patterns differed by race. Among White men, compared with urban non-Appalachia, the odds of more aggressive prostate cancer were higher in rural non-Appalachia and rural Appalachia but lower in urban Appalachia. However, among Black men, those residing in rural Appalachia had significantly lower odds than those residing in urban non-Appalachia. Older age, Hispanic ethnicity, higher serum PSA, and lymph node-positive status were also associated with higher odds of more aggressive prostate cancer. CONCLUSION: Prostate cancer burden and severity varied by Appalachian status and rurality, supporting targeted, region- and race-specific strategies to improve early detection and access to high-quality care.