Prostate Cancer Outcomes by Race & Treatment Site Drs. Kurian, Washington, Nielsen-Menicucci

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.