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Prostate Cancer Outcomes by Race

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Morbidity after Prostate Cancer ... Results from the prostate cancer outcomes study. ... evaluate patient function and bother after prostate cancer treatment ... – PowerPoint PPT presentation

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Title: Prostate Cancer Outcomes by Race


1
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."
2
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
3
Racial Distribution of Prostate Cancer
Prostate Cancer Trends 1973-1995
4
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.
5
Background
  • Overall 5-year relative survival rate for
    prostate cancer among African Americans is 98
    compared to 100 among whites.
  • 80 of AAs 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

6
Explanatory Theories
  • Biologic Hypothesis
  • Differences in susceptibility
  • Differences in tumor virulence
  • Access Hypothesis
  • Socioeconomic issues
  • Literacy
  • Access to care

7
Environmental Issues
  • Dietary preferences among the races may account
    for differences in prostate cancer rates.

8
Oncology Health Disparities Model
Personal Health Beliefs
Lifestyle Factors/Environment
Tumor Biology/Genetics
Health-System Factors
Personal Health Beliefs
Tumor Biology
Comorbidities
Quality of Treatment
Post-Treatment Surveillance
Health System Factors
Tolerance of Treatment
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.
9
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.

10
Mortality Literature Review
11
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

12
Morbidity after Prostate Cancer
  • Similar variability noted in reporting of urinary
    and bowel symptoms.
  • Wide variations in reporting of morbidity between
    races.

13
  • 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.

14
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.
15
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 trials
  • Use of specialist to staff intensive care units
  • High 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.
16
Does NCI designation exert an effect on outcomes ?
  • National Cancer Act
  • Establish regional centers of excellence in
    research and patient care.
  • To be NCI designated
  • Excellence in Research
  • Excellence in Cancer Prevention
  • Excellence in Clinical Services.

17
NCI-Designation
  • One study using Medicare database
  • Mortality 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.
18
Does Utilization of Care Differ between Blacks
and Whites
  • Disparities exist in a variety of health service
    categories
  • Range 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.
19
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.
20
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.
21
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

22
Data Sources
  • Office of Statewide Health Planning and
    Development.
  • Secondary quality indicators
  • Teaching status, bed size, hospital location
  • EPIC
  • Morbidity information

23
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

24
EPIC
25
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

26
Symptom Schedule
27
Patient Population
  • Mortality
  • All African-American (N5,215) and non-Hispanic
    Caucasian (n16,789) 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 (n1,619)
    as well as a set of non-Hispanic Caucasian cases
    (n2,581) randomly sampled to match the
    frequencies for age, disease stage and grade in
    the African-American cohort

28
Supplementary Studies
  • Impact of distance from NCI center
  • Using 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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