prostate cancer outcomes by race & treatment site drs. kurian, washington, nielsen-menicucci
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Prostate Cancer Outcomes by Race & Treatment SiteDrs. Kurian, Washington, Nielsen-Menicucci
Farm Security Administration-Office of War Information file of photographic prints Durham, North Carolina. May 1940. Jack Delano, photographer. A cafe near the tobacco market." [Signs: Separate doors for "White" and for "Colored."]
Background
An estimated 30,870 cases among AA in 2007
37% of all cancers in AA men Between 2000-2003, The average
annual prostate cancer incidence rate was 60% higher in AA than in white men
Hayat, M.J., et al., Cancer statistics, trends, and multiple primary cancer analyses from the Surveillance, Epidemiology, and End Results (SEER) Program. Oncologist, 2007. 12(1): p. 20-37
Racial Distribution of Prostate Cancer
Prostate Cancer Trends 1973-1995
Background
This difference accounts for about 40% of the overall cancer mortality disparity between African American and white men.
ACS (2007) Cancer Facts and Figures for African Americans 2007-2008.
Background
Overall 5-year relative survival rate for prostate cancer among African Americans is 98% compared to 100% among whites.
80% of AA’s are diagnosed in local or regional stages
So morbidity is an equally important outcome of interest.
Hayat, M.J., et al., Cancer statistics, trends, and multiple primary cancer analyses from the Surveillance,
Epidemiology, and End Results (SEER) Program. Oncologist, 2007. 12(1): p. 20-37
Explanatory Theories
Biologic HypothesisDifferences in susceptibilityDifferences in tumor virulence
Access HypothesisSocioeconomic issues
• Literacy• Access to care
Environmental Issues
Dietary preferences among the races may account for differences in prostate cancer rates.
Oncology Health Disparities Model
-Receipt of Treatment
-Benefit of Treatment
Diagnosis-Higher incidence-Advanced Stage
Cancer-SpecificMortality
Personal Health Beliefs
Health-System Factors
Lifestyle Factors/Environment
Tumor Biology/Genetics
Personal Health Beliefs
Comorbidities
Health System Factors
Quality of Treatment
Tolerance of Treatment
Post-Treatment Surveillance
Tumor Biology
Polite BN, Dignam JJ, Olopade OI, Colorectal Cancer Model of Health Disparities: Understanding Mortality Differences in Minority Populations.J Clin. Oncol, 2006 24(14): p. 2179-2187.
Access to care
There seemed to be disparate findings in the literature about mortality outcomes after treatment for prostate cancer.
Single institution or multi-large center studies found that mortality was equivalent with equivalent treatment
Population based studies, do not support these findings.
Mortality Literature Review
Study Study Type Sample Size Treatment Mortality
Underwood et al. Single Institution 1,177 White, 51 Black Surgery Equivalent
Sohayda et al. Single Institution 1901 White, 318 Black Radiation/Surgery Equivalent
Iselin et al. Single Institution 1204 White, 115 Black Surgery Equivalent
Johnston et al. Multi-large Institution 1349 White, 343 Black Radiation/Surgery Equivalent
Lee et al. Single Institution 835 White, 246 Black Radiation Equivalent
Freedland M et al Multi-large Institution 1014 White, 338 Black Surgery Equivalent
Hart KB, et al Single Institution 387 Whites, 306 Black Surgery/Radiation Equivalent
Robbins AS et alPopulation based/Cancer Registry 15,177 Whites, 2551 Blacks Surgery/Radiation Different
Goodley PA et alPopulation based/SEER-Medicare 38,242 Whites, 5747 Blacks Surgery/Radiation Different
Pienta KJ et al Population based/SEER 9339 Whites, 3568 Blacks Not evaluated Different
Morbidity after Prostate Cancer Type of Study
Erectile dysfunction after radical prostatectomy• Population-based studies : 53%-88%• Single Institution: 22%-90%
Erectile dysfunction after external beam radiation• Population-based studies: 23%-67%• Single Institution: 7%-63%
Erectile dysfunction after brachytherapy• Population-based studies: 8%• Single Institution: 16%-50%
Morbidity after Prostate Cancer
Similar variability noted in reporting of urinary and bowel symptoms.
Wide variations in reporting of morbidity between races.
Hypothesis 1: African-Americans with newly diagnosed prostate cancer have a higher incidence of mortality and morbidity compared to Caucasians after controlling for age, stage, grade and treatment modality
Hypothesis 2: Patients with newly diagnosed prostate cancer, receiving care at NCI designated Cancer Centers have a lower incidence of mortality and morbidity, irrespective of race and ethnicity, when compared with those treated at non-NCI cancer centers.
Hypothesis 3: African-Americans and Caucasians receiving care at NCI-designated cancer centers have comparable mortality and morbidity.
Hypothesis 4: Proportionately fewer African-Americans utilize NCI cancer centers when compared to Caucasians.
Does Where You Get Treatment really make a difference? Mortality in General:
Volume seems to make a difference• Supported by lit review of 135 studies• Cohort study using SEER data
Mortality After Prostate Cancer Volume seems to make a difference Review of 101,604 Medicare claims data Nationwide Inpatient Sample
• Prostatectomies between 1989-1995
Halm, E.A., C. Lee, and M.R. Chassin, Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med, 2002. 137(6): p. 511-20.
Yao, S.L. and G. Lu-Yao, Population-based study of relationships between hospital volume of prostatectomies, patient outcomes, and length of hospital stay. J Natl Cancer Inst, 1999. 91(22): p. 1950-6.
Does Where You Get Treatment really make a difference? Morbidity after Prostate Cancer
Volume linked to decreased rates of postoperative and late urinary complications
Participation in clinical trialsUse of specialist to staff intensive care
unitsHigh nurse-to-bed ratios
Begg, C.B., et al., Impact of hospital volume on operative mortality for major cancer surgery.
Jama, 1998. 280(20): p. 1747-51.
Does NCI designation exert an effect on outcomes ?
National Cancer ActEstablish regional centers of
excellence in research and patient care.
To be NCI designated• Excellence in Research• Excellence in Cancer Prevention• Excellence in Clinical Services.
NCI-Designation
One study using Medicare databaseMortality after cystectomy, colectomy,
pulmonary resections, pancreatic resection, gastrectomy and esophagectomy
NCI Centers had lower operative mortality in 4/6 procedures
NCI Centers had lower overall mortality in 2/6 procedures.
Birkmeyer, N.J., et al., Do cancer centers designated by the National Cancer Institute have better surgical outcomes? Cancer, 2005. 103(3): p. 435-41.
Does Utilization of Care Differ between Blacks and Whites
Disparities exist in a variety of health service categoriesRange from pediatric/ maternal and
child health to rehabiliatative and nursing home services.
Disparities in care resulted in disparities in mortality
Nelson, A., Unequal treatment: confronting racial and ethnic disparities in health care. J Natl Med Assoc, 2002. 94(8): p. 666-8.
Does Utilization of Care Differ between Blacks and Whites (Prostate Cancer)
More likely to receive conservative management
More likely to receive orchiectomy rather than expensive hormonal drug treatments
Shavers, V.L., et al., Race/ethnicity and the receipt of watchful waiting for the initial management of prostate cancer. J Gen Intern Med, 2004. 19(2): p. 146-55.Hoffman, R.M., et al., Racial differences in initial treatment for clinically localized prostate cancer. Results from the prostate cancer outcomes study. J Gen Intern Med, 2003. 18(10): p. 845-53.
Racial differences in the use of centers of excellence Only one study
utilization of high-volume hospitals for complex surgery
overall non-whites, Medicaid patients and uninsured patients were less likely to receive care at high-volume hospitals
No studies looking at differences in the use of NCI designated centers
Liu, J.H., et al., Disparities in the utilization of high-volume hospitals for complex surgery. Jama, 2006. 296(16): p. 1973-80.
Data Sources California Cancer Registry
Demographic• Race, SES, census tract, age, marital status, zip
code
Tumor information• Stage, grade
Treatment information• Surgery, radiation, hormone therapy, location of
therapy, NCI status of institution,
Vital Status
Data Sources
Office of Statewide Health Planning and Development.Secondary quality indicators
• Teaching status, bed size, hospital location
EPICMorbidity information
EPIC
Expanded Prostate Cancer Index Composite designed to evaluate patient function
and bother after prostate cancer treatment
evaluated in the domains of urinary function, bowel habits, sexual function and hormonal function
EPIC
EPIC supplement
Will ask patients to indicate when they first noticed symptoms and when these symptoms resolved.Allows us to make some inference
regarding the effect of treatment on the development of the morbidity
Symptom Schedule
Patient Population
Mortality: All African-American (N=5,215) and non-Hispanic
Caucasian (n=16,789) cases with newly diagnosed prostate cancer reported to the CSP from 1998-2003.
Morbidity: All African-American patients with newly diagnosed
prostate cancer reported to the CSP between January 2002 and December 2003 (n=1,619) as well as a set of non-Hispanic Caucasian cases (n=2,581) randomly sampled to match the frequencies for age, disease stage and grade in the African-American cohort
Supplementary Studies
Impact of distance from NCI centerUsing GIS and location of patient,
treatment, reporting hospitals and nearest NCI center
Effect of other quality indicators such as teaching status, bed size and possibly volume on mortality and morbidity.
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