3 articles need to answer these questions: What are the elements of the study design, and why the authors made the choices they did? Identify the importance of this study and what it adds to the knowl

Precision Medicine in Health Disparities Research IntroductIon Prostate cancer is one of the lead - ing causes of cancer among men in the United States. 1 In addition to African American race, established risk factors for prostate cancer include family his - tory of prostate cancer and increasing age; the average age at prostate cancer diagnosis is sixty-six years. 1 Increasing age is also a risk factor for developing chronic conditions that include hy - pertension, diabetes, high cholesterol, and cardiovascular disease. 2 Thus, as men age, they are at risk for develop - ing multiple acute and chronic condi - tions that increase their likelihood of morbidity and mortality. A substan - tial proportion of prostate cancer pa - tients have at least one co-morbidity, or a chronic condition that is distinct from their primary prostate cancer di - agnosis. 3 Previous research has shown that being diagnosed with prostate cancer and having a co-morbid con - dition (eg, diabetes, hypertension, cardiovascular disease) is associated with an increased risk of dying from causes other than prostate cancer. For example, prostate cancer patients in the Surveillance, Epidemiology, and Endpoints Registry (SEER) who had two or more chronic conditions had a 43% to 48% chance of dy - ing from any cause within five years of their prostate cancer diagnosis. 4 Because co-morbidities are com - mon among men who have a per - sonal history of prostate cancer and these other chronic conditions may C o -morbidities in a r etrospe Ctive C ohort of p rostate C an Cer p atients Melanie Jefferson, PhD 2,3; Richard R. Drake, PhD 1,2; Michael Lilly, MD 2,4; Stephen J. Savage, MD 2,5; Sarah Tucker Price, MD 6; Chanita Hughes Halbert, PhD 2,3 Objective: To characterize rates of co- morbidity among prostate cancer patients treated with radical prostatectomy and to examine the association between co-mor - bidity status and race, clinical factors, and health behaviors for cancer control.

Design/Study Participants: Retrospective cohort study among prostate cancer patients treated with radical prostatectomy.

Setting: Academic medical center located in the southeastern region of the United States.

Main Outcome Measure: Patients with at least one of five co-morbid conditions considered were categorized as having a co-morbidity, and those without any were categorized as not having a co-morbid condition. Co-morbid conditions consid - ered were hypertension, diabetes, heart problems, stroke, and high cholesterol, which had been recorded in the electronic medical record as part of their past medical history.

Results: Fifty-one percent of participants had a co-morbidity, with hypertension being the most common. The average number of co-morbidities among study participants was .87. In a multivariate logistic regression analysis, being diagnosed with prostate can - cer within the past four years was associated with an increased likelihood of having a co- morbidity (OR=4.71, 95% CI=2.69, 8.25, P=.0001) compared with diagnosis five or more years ago. Age was also associated with an increased likelihood of having a co- morbidity (OR=1.30, 95% CI=1.005, 1.68, P=.05). In this study cohort, race, stage at diagnosis, and PSA level were not statisti - cally associated with co-morbidity status.

Conclusion: Better chronic disease management is needed among prostate cancer survivors through more effective survivorship care planning and interventions that promote health behaviors. Ethn Dis. 2020;30(Suppl 1):185-192; doi:10.18865/ ed.30.S1.185 Keywords: Co-morbidities, Retrospective Cohort, Prostate Cancer 1 Department of Cell and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, SC2 Hollings Cancer Center, Medical University of South Carolina, Charleston, SC 3 Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC4 Department of Medicine, Medical University of South Carolina, Charleston, SC5 Department of Urology, Medical University of South Carolina, Charleston, SC6 Department of Family Medicine, Medical University of South Carolina, Charleston, SC Address correspondence to Chanita Hughes Halbert, PhD, Medical University of South Carolina, 68 President Street, Suite BE103, Charleston, SC 29425; 843.876.2421; [email protected] Ethnicity & Disease, Volume 30, Supplement 1, 2020 186 be their cause of death, co-morbidity status should be integrated and con - sidered as part of making decisions about prostate cancer treatment. 5-7 To do this, it is important to have an understanding of the distribution of co-morbidities among diverse patient populations. In population-based samples, for instance, African Ameri - cans are more likely to have hyperten - sion and cardiovascular disease com - pared with Whites. 8,9 Characterizing the distribution of co-morbidities specifically among men who have a personal history of prostate cancer is To extend previous research that examined co-morbidity in prostate cancer patients who were treated with all treatment modalities, 3 the purpose of this study was to characterize co- morbidities among prostate cancer patients treated with radical prosta - tectomy. Because of racial differences in the rates of chronic conditions (eg, hypertension, cardiovascular disease), we were also interested in determin - ing if minority and non-minority prostate cancer patients differed in terms of having co-morbidities and the types of chronic conditions with which they have been diagnosed.

We hypothesized that minority pa - tients would be more likely to have at least one co-morbidity compared with non-minority patients. An ad - ditional objective of this study was to examine the association between co-morbidities and tumor char - acteristics (eg, stage of disease) to provide insight about how adverse prognostic factors for prostate can - cer are associated with the potential risk of death from chronic conditions among prostate cancer survivors.

Lastly, since dietary behaviors and physical activity are behavioral risk factors for chronic conditions, 12 we also examined the relationship be - tween co-morbidity status and fruit/ vegetable intake and physical activity.

M ater Ia ls a nd M ethods Study Population Participants in this study were men who had a personal history of prostate cancer and had provided a tissue sample as part of having a radi - cal prostatectomy. Prostate cancer tis - sue samples were collected by the Bio - repository and Tissue Analysis (BTA) Shared Resource at the Hollings Can - cer Center (HCC) after patients pro - vided written informed consent and privacy authorization using institu - tional guidelines at the Medical Uni - versity of South Carolina (MUSC).

As part of this informed consent process, men agreed for their tissue samples to be used as a part of cancer research and agreed to be contacted about participating in future studies.

More than 90% of prostatectomy pa - tients provided consent for their tis - sue sample to be stored in the BTA.

The HCC Biorepository was queried to identify men who had an ICD-10-CM code of C61 (malignant neoplasm of prostate) and CPT codes of 55810 (prostatectomy, perineal radical) and 55866 (laparoscopic pro - cedures on the prostate) since 2011.

The resulting study sample included 316 prostate cancer patients who had a tissue sample available in the HCC Biorepository when study recruitment was initiated in 2016. Of these 316, 83 (26%) completed a structured so - cial determinants survey that provid - ed the data to examine the association between health behaviors for can - cer control and co-morbidity status.

Procedures All study procedures were ap - proved by the institutional review board at MUSC. First, information on sociodemographic characteristics (eg, race, age), prostate cancer vari - ables, and co-morbidities was ab - stracted from the electronic health record (EHR) of eligible patients who were identified from the HCC Biore - pository. Next, patients were contact - …the purpose of this study was to characterize co- morbidities among prostate cancer patients treated with radical prostatectomy.

also important for survivorship care planning. This is especially true given that it was estimated that 164,690 new prostate cancer cases would occur in 2018 with only 29,430 deaths. 10 Receiving quality care for co-morbidities during and after the acute treatment phase for cancer is necessary to reduce the likelihood of morbidity and mortality from chron - ic illnesses among cancer patients. Re - cent research has shown that having a greater number of co-morbidities and being African American are associ - ated with wanting more information to help guide their follow-up care. 11 Ethnicity & Disease, Volume 30, supplement 1, 2020 Co-morbidities in Prostate Cancer Patients - Jefferson et al 187 ed by mailed invitation to complete a structured telephone interview that measured social determinants and health behaviors for cancer control.

Patients could decline to participate in the social determinants survey by contacting the program manager at MUSC by telephone or email.

Those who did not decline to com - plete the social determinants survey were contacted by a research assistant at MUSC to complete a 30-min - ute social determinants survey. Measures The following data elements were abstracted from the EHR for each study participant: year of birth; date of diagnosis; prostate specific anti - gen (PSA) levels at diagnosis; patho - logic stage at diagnosis (T1a; T1c; T2a; T2b; T2c; T3a; T3b); Gleason score; race (White, African Ameri - can); height; weight; and systolic and diastolic blood pressure at the time of the pre-surgical consultation visit.

Co-morbidities were obtained from the patient’s problem list as recorded in the EHR. Patients were categorized as having a history of hypertension (yes or no), diabetes (yes or no), heart problems (yes or no), stroke (yes or no), or high cholesterol (yes or no).

We focused on these chronic condi - tions because they are among the leading causes of morbidity and mor - tality in the United States 13 and have been associated with an increased risk of all-cause mortality among prostate cancer patients. 4,14 Height and weight values were used to calculate body mass index using the Centers for Dis - ease Control and Prevention BMI calculator. 15 Stage was recoded into a binary variable of early vs later stage disease (T1/T2 vs T3). The amount of time since diagnosis was calculated based on the date of diagnosis. We recoded time since diagnosis into a binary variable of within the past four years or five or more years from the date study recruitment was initiated. The social determinants survey as - sessed self-reported race and ethnic - ity, self-report on the co-morbidities in the study, and fruit/vegetable in - take and physical activity using items from the Health Information Nation - al Trends Survey (HINTS). 16 Specifi - cally, men were asked how many cups of fruit and vegetables they eat each day (1=none/don’t know, 2=½ cup or less, 3=½ to 1 cup, 4=1 to 2 cups, 5=2 to 3 cups, 6=3 to 4 cups, 7=more than four cups). Men who reported eating at least 2 to 3 cups were categorized as meeting recommended guidelines for each dietary behavior variable.

Next, men were asked if they had par - ticipated in any physical activities or exercises during the past month (yes or no). Those who reported yes were asked how many days they were phys - ically active or exercised of at least moderate intensity and on these days, how long they typically performed these behaviors. The total number of minutes for moderate intensity physi - cal activity per week was calculated by multiplying the number of days by the minutes reported. Men who reported no physical activity during the past month, those who reported that they had been physically active during the past month, but had not been active during the past week, and those who reported physical activity, but did not meet the physical activ - ity guidelines (eg, less than 150 min - utes/week) were coded as not meeting guidelines. 17 The remaining partici - pants were coded as having met the guidelines for physical activity. 17 Data Analysis Descriptive statistics were gener - ated first to characterize the study patients (n=316). Next, frequencies were generated to identify the co- morbidities that were most and least common among participants. Chi square tests of association and t-tests were performed to examine the asso - ciation between co-morbidity status, race, and clinical variables. Variables that had a bivariate association of P<.25 with co-morbidity status were included in the multivariate logistic regression analysis. Lastly, multivari - ate logistic regression analysis was used to identify factors having signifi - cant independent associations with co-morbidity status. Race was also included in the regression model re - gardless of the significance of the bi - variate association with co-morbidity status because of disparities in chron - ic diseases. This same approach was used to examine the relationship be - tween co-morbidity status and fruit/ vegetable intake and physical activ - ity in the sub-set of men who com - pleted the social determinants survey. r esults Table 1 shows the characteristics of the study patients. Thirty-two per - cent of patients were racial minori - ties (eg, African American) and 68% where non-minorities. The mean (SD) age was 65.2 (6.7). With respect to prostate cancer variables, the mean PSA was 9.2 (SD=10.9) and 77% of Ethnicity & Disease, Volume 30, Supplement 1, 2020 Co-morbidities in Prostate Cancer Patients - Jefferson et al 188 men had been diagnosed with stage T2 disease and 23% had been diag - nosed with stage T3 disease. In addi - tion, 72% of men had a Gleason score of 3+4 or 3+3. Sixty-nine percent of men were diagnosed within the past four years and 31% were diagnosed more than five years ago. In the sub- set of men who completed the social determinants survey, 31% met guide - lines for fruit intake, 25% met guide - lines for vegetable intake, and 30% met guidelines for physical activity.

With respect to co-morbidity status, 51% of men had at least one co-morbid condition; men were most likely to have high blood pres - sure (42%), high cholesterol (24%), diabetes (12%), heart problems (9%), and stroke (.63%). Among those who had at least one co-morbidity, the mean (SD) number was .87 (1.02).

Table 2 shows the results of the bivariate analyses of co-morbidity.

Time since diagnosis had significant bivariate association with co-morbid - ity status. Men who were diagnosed within the past four years were more likely to have a co-morbidity com - pared with those who were diagnosed more than four years ago (61% vs 30%, chi square=25.4, P=.0001).

The mean PSA was also higher among men who had a co-morbid - ity (mean=10.2, SD=13.6) com - pared with those who did not have a co-morbidity (mean=8.2, SD=6.6) (t=-1.70, P=.09). Sixty-one percent of men who had stage T3 disease had a co-morbidity compared with 49% of men who were diagnosed with stage T2 disease (chi square=3.04, P=.08).

There were also small mean differ - ences in age based on co-morbidity status. For instance, the average (SD) age was 65.7 (6.5) among men who had a co-morbidity compared with 64.8 (7.0) among those without any co-morbidities (t=-1.20, P=.23).

Fifty-five percent of men from racial minority groups had a co-morbidity compared with 49% of non-minor - ity men (chi square=1.04, P=.31).

BMI was similar between men who had at least one co-morbid condi - tion (mean=29.5, SD=5.6) and those who did not have any co-morbidities (Mean=29.4, SD=4.4) (t-value=-.20, P=.84). Among the sub-set of men who completed the social determi - nants survey, none of the behavioral risk factors (fruit/vegetable intake or physical activity) were associated sig - nificantly with having a co-morbidity.

The results of the multivariate lo - gistic regression model of co-morbidi - ty status are provided in Table 3. Only time since diagnosis had significant independent association with having a co-morbid condition. Men who were diagnosed within the past four years had a greater likelihood of hav - ing a co-morbid condition compared with those who were diagnosed more than four years ago (OR=4.71, 95% CI=2.69, 8.25, P=.0001). The likeli - hood of having a co-morbid condition increased with older age (OR=1.30, 95% CI=1.005, 1.68, P=.05).

d Iscuss Ion The purpose of this study was to examine co-morbidity rates among prostate cancer survivors who were treated with radical prostatectomy.

Overall, 51% of men had one co- morbidity, the average number of co-morbidities was .87, and high blood pressure was the most com - mon co-morbid condition. Forty- two percent of men had high blood pressure, but less than 1% had a his - tory of stroke. Chronic disease man - agement among cancer patients and survivors is an important priority 18; our findings underscore the need for greater chronic disease management among prostate cancer patients, re - gardless of their racial background, especially when they are within the first four years of being diagnosed.

The overall rates for co-morbidi - ties in our sample were higher than those reported in previous research, 3 but there was some consistency in the Table 1. Study patient characteristics Variable Level n (%) Race Minority 101 (32%) Non-minority 215 (68%) Gleason score 4+3/4+4/4+5/5+3/5+5 79 (28%) 3+3/3+4 201 (72%) Stage T3 69 (23%) T2 229 (77%) Time since diagnosis Within past four years 217 (69%) Five or more year 99 (31%) Age Mean (SD) 65.2 (6.7) PSA Mean (SD) 9.2 (10.9) BMI Mean (SD) 29.4 (5.0) Ethnicity & Disease, Volume 30, supplement 1, 2020 Co-morbidities in Prostate Cancer Patients - Jefferson et al 189 rates for individual co-morbidities in our sample and other studies. For in - stance, Edwards et al 3 found that 13% of prostate cancer patients in a na - tional sample had a history of diabetes whereas 11% of patients in our study had a history of this disease. Further, 56% of prostate cancer patients who had a radical prostatectomy reported a history of hypertension 18 and 42% patients in our sample had hyperten - sion. However, 30.5% of prostate cancer patients in a national sample had at least one co-morbidity. 3 Our higher overall rates of co-morbidity may be due to our including hyper - tension, whereas other studies, in - cluding the study by Edwards and colleagues, based co-morbidity on conditions included in the Charlson Co-Morbidity Index, which does not include hypertension. 3,19,20 Together with the findings from previous stud - ies demonstrating that hypertension is associated with an increased risk of biochemical recurrence among men treated with radical prostatectomy, 21,22 the exclusion of hypertension in stud - ies that examine prostate cancer out - comes may be a significant omission.

In addition to being a risk factor for all-cause mortality and death from cardiovascular disease, 9 hypertension was associated with an increased risk of biochemical recurrence among prostate cancer patients. 21,22 There continues to be significant racial dis - parities in prostate cancer incidence and mortality. 1 African American men have the greatest incidence of pros - tate cancer among men in the United States and are about twice as likely as White men to die from this disease. 1 Previous research has shown that Af - rican Americans are more likely than Whites to have high blood pressure. 9 Specifically, hypertension was associ - ated with a two-fold increase in bio - chemical recurrence among African American and White men who were treated with radical prostatectomy. 22 While Post and colleagues 22 found that African American prostate can - cer patients were significantly more likely to have hypertension compared with White patients, there were non - significant racial differences in overall rates of hypertension in our study and mean levels of systolic and diastolic blood pressure did not differ between Table 2. Bivariate analysis of comorbidity status Variable Level % Comorbidity Chi Square P Race Minority 55% 1.04 .31 Non-minority 49% Gleason score 4+3/4+4/4+5/5+3/5+5 52% .03 .86 3+3/3+4 51% Stage T3 61% 3.04 .08 T2 49% Time since diagnosis Within past four years 61% 25.4 .0001 Five or more year 30% Co-MorbidityMean (SD) No-Comorbidity Mean (SD) T-Value P Age 65.7 (6.5) 64.8 (7.0) -1.20 .23 BMI 29.5 (5.6) 29.4 (4.4) -.20 .84 PSA 10.2 (13.6) 8.2 (6.6) -1.70 .09 Table 3. Logistic regression model of comorbidity Variable Level Odds ratio 95% CI P Race Minority 1.56 .90, 2.69 .11 Non-minority Age a 1.30 1.005, 1.68 .05 Stage T3 1.20 .65, 2.21 .56 T2 Time since diagnosis Within past four years 4.71 2.69, 8.25 .0001 Five or more years PSA a 1.17 .85, 1.61 .33 a. ORs for continuous variables reflect the OR for a 1-SD unit change in the covariate.

Ethnicity & Disease, Volume 30, Supplement 1, 2020 Co-morbidities in Prostate Cancer Patients - Jefferson et al 190 minorities and non-minorities in our sample (data not shown). However, our sample showed higher blood pressures and higher BMI measures overall. The average (SD) systolic and diastolic blood pressures were 142.1 (17.5) and 82.3 (9.3), respec - tively, the average (SD) BMI was high (29.4, 5.0), and 37% of men in our sample were obese. This may explain why there were no racial differences in co-morbidity status in our study.

We found that men who had been diagnosed with prostate cancer within the past four years had a sig - nificantly increased likelihood of hav - ing a co-morbid condition compared with those who had been diagnosed five or more years ago. This may be due to temporal changes in the ex - tent to which co-morbidities are re - corded in electronic medical records.

All health care providers and systems were required to implement and dem - onstrate meaningful use of electronic medical records in January 2014 23; there may be greater documentation of co-morbidities in electronic medi - cal records as information systems were introduced and expanded to meet federal requirements. However, recent research has shown high agree - ment between patient self-reported co-morbidities and documentation of these conditions in the medical re - cord. 24 Further, a similar proportion of men had specific co-morbidities based on self-report and electronic medical record. For instance, 44% of men self-reported hypertension and 44% of men had hypertension according to the electronic health record. Similarly, 8% of men self-re - ported a personal history of diabetes.

Additional research is needed to de - termine why men who have a shorter time from prostate cancer diagno - sis are more likely than longer-term survivors to have a co-morbidity.

Interestingly, none of the behav - ioral risk factors (eg, diet, physical activity) for co-morbidities were as - sociated significantly with having a chronic disease among men who completed the social determinants survey. This may be due to the small number of men who were included in this analysis; however, it is important to note that a minority of these partic - for chronic disease management 25; and our findings emphasize the im - portance of developing behavioral interventions to enhance these behav - iors in prostate cancer survivors, espe - cially those who have a co-morbidity. Study Limitations In considering the results of this study, some limitations should be noted. First, co-morbidities were ex - amined among men who were treated with radical prostatectomy at one academic health center, and men who have several comorbid condi - tions do not receive surgery as their primary treatment. Therefore, our study may reflect the lowest percent - age of co-morbidity for prostate can - cer diagnosis. Co-morbidities should be examined among men who have been treated with different modali - ties at diverse academic and commu - nity oncology clinical settings. Sec - ondly, co-morbidity was determined based on the presence of the leading causes of death in the United States (eg, cardiovascular disease, stroke, hypertension, diabetes) at the time of medical abstraction in a retrospective cohort of prostate cancer patients.

Other co-morbidity indices include a more extensive list of conditions 20; however, these measures may not ask about chronic diseases that are com - mon in minority populations. No - tably, the inclusion of hypertension in our measure of co-morbidity may be a better reflection of the chronic disease burden in diverse samples of prostate cancer patients. Lastly, it is also important to determine co-mor - bidity status prospectively at the time of diagnosis to be able to examine the association between chronic condi - Overall, 51% of men had one co-morbidity, the average number of co- morbidities was .87, and high blood pressure was the most common co-morbid condition. ipants met recommended guidelines for fruit/vegetable intake and physical activity. Recommendations for physi - cal activity cancer survivors include 150 minutes of moderate intensity exercise weekly 25; however, only 30% of men in our study met this recom - mendation. Similarly, only 31% and 25% met recommended guidelines for fruit and vegetable intake, respec - tively. Diet behaviors and physical activity are important strategies for cancer control among prostate cancer survivors and are also recommended Ethnicity & Disease, Volume 30, Supplement 1, 2020 Co-morbidities in Prostate Cancer Patients - Jefferson et al 191 tions and prostate cancer outcomes.

Detailed information on when prostate cancer patients were diag - nosed with chronic diseases should be captured as part of prospective studies to understand the trajectory of co-morbidity in these patients.

Study Implications Despite these potential limita - tions, the results of our study have important implications for prostate cancer survivorship. First, our find - ings demonstrate that chronic disease management is needed among pros - tate cancer patients. Survivorship care plans are now being implemented at the conclusion of cancer treatment to facilitate the patient’s transition back to primary care by summariz - ing their cancer diagnosis, treatment, and follow-up care 26,27; however, our findings suggest that efforts may also be needed to manage diseases such as hypertension and to promote cancer control behaviors at all phases of can - cer survivorship. A little more than 50% of the patients in our study had at least one co-morbidity, 37% were obese, and only about one third of men met recommended guidelines for diet and physical activity. Although we were not able to determine the specific age and date at which men were diagnosed with co-morbid con - ditions such as diabetes and hyper - tension because this information was not recorded in the electronic medi - cal record, blood pressure and obe - sity were measured at the time of the pre-surgical consultation visit. Fur - ther, the mean levels for systolic and diastolic blood pressure were above normal ranges and 87% and 57% of participants in our study had values that were above 120 mm Hg and 80 mm Hg, respectively, regardless of hy - pertension status. Blood pressure may have been elevated due to anxiety at the time of the pre-surgical consul - tation visit. However, national data show that only about 50% of individ - uals who have hypertension have this condition under control, men were less likely than women to have con - trolled hypertension, and there are racial differences in the rates of con - trolled disease in national samples. 28 Research in breast cancer patients has shown that adherence to noncan - cer medications for chronic condi - tions decreases during the first year after treatment; potential reasons for reduced adherence to noncancer medications include greater priori - tization of cancer treatment and fi - nancial toxicity. 29 To our knowledge, financial toxicity and adherence to noncancer medications has not been examined specifically among prostate cancer patients and these are impor - tant areas for future research. Because of the high burden of chronic disease and the potential for cancer patients to reduce their adherence to noncan - cer medications following their diag - nosis and treatment, 29 primary care services may need to be integrated into oncology care. Primary care on - cology is emerging as a cancer care service in which providers focus on the medical and psychological impact of cancer treatment, with the manage - ment of co-morbidities as one com - ponent of this specialty. 30,31 Primary care oncologists could play an impor - tant role in managing co-morbidities at diagnosis, through treatment, and during short- and long-term survi - vorship among prostate cancer pa - tients. Future studies are needed to evaluate the impact of primary care oncology on the management of co- morbidities and prostate cancer out - comes in diverse patient populations.

acknowledgeMents This study was supported by National Institute of Minority Health and Health Dis - parities grant #U54MD010706. This study was also supported in part by the Bioreposi - tory and Tissue Analysis Shared Resource at the Hollings Cancer Center at the Medical University of South Carolina through grant #P30CA138313 from the National Cancer Institute. We are very appreciative to Tamara Dobson-Brown for assistance with data col - lection and management. We would like to thank the men who participated in this study.

Conflict of Interest No conflicts of interest to report.

Author Contributions Research concept and design: Jefferson, Drake, Savage; Acquisition of data: Jefferson, Lilly, Savage; Data analysis and interpreta - tion: Jefferson, Lilly, Savage, Tucker Price; Manuscript draft: Jefferson, Drake, Lilly, Tucker Price; Acquisition of funding: Drake; Administrative: Jefferson, Lilly, Savage, Tucker Price; Supervision: Jefferson, Savage References1. American Cancer Society. Cancer Facts and Figures, 2018 . Atlanta, GA: American Cancer Society; 2018. 2. World Health Organization. Chronic Diseases and their Common Risk Factors . Available at: https://www.who.int/chp/chronic_disease_re - port/media/Factsheet1.pdf . 3. Edwards BK, Noone AM, Mariotto AB, et al. Annual Report to the Nation on the status of cancer, 1975-2010, featuring prevalence of comorbidity and impact on survival among persons with lung, colorectal, breast, or prostate cancer. Cancer . 2014;120(9):1290- 1314. https://doi.org/10.1002/cncr.28509 PMID:24343171 4. Albertsen PC, Moore DF, Shih W, Lin Y, Li H, Lu-Yao GL. Impact of comorbidity on survival among men with localized prostate cancer. J Clin Oncol . 2011;29(10):1335-1341. https://doi.org/10.1200/JCO.2010.31.2330 PMID:21357791 5. American Urological Association. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Available at: https://www.auanet.

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Ethnicity & Disease, Volume 30, Supplement 1, 2020 Co-morbidities in Prostate Cancer Patients - Jefferson et al