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Racial Disparities and Socioeconomic Status in Association with Survival in Older Men with Local/Regional Stage Prostate Cancer

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Racial Disparities and Socioeconomic Status in Association with Survival in Older Men with Local/Regional Stage Prostate Cancer Xianglin L. Du, M.D., Ph.D. – PowerPoint PPT presentation

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Title: Racial Disparities and Socioeconomic Status in Association with Survival in Older Men with Local/Regional Stage Prostate Cancer


1
Racial Disparities and Socioeconomic Status in
Association with Survival in Older Men with
Local/Regional Stage Prostate Cancer
  • Xianglin L. Du, M.D., Ph.D. Associate Professor
  • University of Texas School of Public Health at
    Houston
  • Division of Epidemiology
  • and Center for Health Services Research

2
Thanks to Coauthors and Collaborators
  • Xianglin L. Du, M.D., Ph.D. Shenying Fang, MD,
    MS,
  • Ann L. Coker, PhD,
  • Maureen Sanderson, PhD,
  • Corrine Aragaki, PhD,
  • Janice N. Cormier, MD, MPH,
  • Yan Xing, MD, MS,
  • Beverly J. Gor, EdD, RD,
  • Wenyaw Chan, PhD

3
Brief Background
  • Racial/Ethnic Disparities in mortality and
    survival present in the U.S.
  • Higher mortality for prostate cancer in African
    Americans compared to Caucasians are attributed
    to
  • More aggressive tumors
  • More advanced stage at diagnosis
  • Health insurance and access to care
  • Difference in screening-early detection
  • Differences in receiving optimal treatments
  • Socioeconomic status
  • Healthcare Providers (physicians and hospitals)

4
Evidence of Racial/Ethnic Disparities in
HealthcareConsistent Findings
  • Disparities consistently found across a wide
    range of disease areas and clinical services
  • Disparities are found even when clinical factors,
    such as stage of disease presentation,
    co-morbidities, age, and severity of disease are
    taken into account
  • Disparities are found across a range of clinical
    settings, including public and private hospitals,
    teaching and non-teaching hospitals, etc.
  • Since disparities in health care are associated
    with poor outcomes they are not acceptable

5
Evidence of Racial/Ethnic Disparities in
Mortality/Survivalnot Consistent Findings
  • Numerous studies showed that the outcomes
    (survival) were similar among different
    racial/ethnic groups, after controlling for
    differences in treatment and socio-demographic
    factors
  • Whereas
  • Other studies showed racial/ethnic disparities
    still existed even after controlling for
    socioeconomic factors and for access to equitable
    care and treatment
  • These inconsistency is also apparent in prostate
    cancer mortality by race/ethnicity

6
Objective and Hypothesis
  • Main objective is to determine whether there is
    racial/ethnic disparity in long-term survival in
    a large nationwide, population-based cohort of
    older men who were diagnosed with locoregional
    stage prostate cancer and who had universal
    fee-for-services Medicare insurance coverage
    (both part A and B).
  • We hypothesized that there were no racial/ethnic
    difference in long-term survival of prostate
    cancer patents after controlling for differences
    in patient characteristics (age), tumor
    characteristics (grade-Gleason score),
    comorbidity, treatment, and socioeconomic status.

7
Study Population and Methods
  • Retrospective cohort study of 61,228 men
    diagnosed with incident (new) local/regional
    stage prostate cancer at age 65 (1992-1999 and
    11 regions)
  • Identified from the NCIs 11 SEER-Medicare data
    (covering gt14 of the U.S. population).
  • Last follow-up 12/31/2002 with up to 11 years of
    FU
  • gt98 completeness of case ascertainment (incident
    cases)

8
Study Variables
  • Outcomes
  • All-cause mortality
  • Prostate cancer-specific mortality
  • Time to event (in months from date of diagnosis
    to date of death)
  • Exposures
  • Race/ethnicity African American, Caucasian, and
    Hispanics
  • Other covariates
  • Demographics (age)
  • Comorbidity index adjustment (created from
    Medicare claims)
  • Locoregional stage, but control for grade and
    AJCC stage for residual confounding
  • Treatment (discuss below)
  • Year of diagnosis (1992 to 1999)
  • Geographic areas (11 areas)
  • Socioeconomic factors (discuss below)

9
Socioeconomic Factors (from 1990 census)
  • Education - percent of adults aged 25 who had
    less than 12 years of education at the zip code
    level, which was categorized into quartiles.
    Poverty - percent of persons living below the
    poverty line at the census tract level
  • Income - median annual household income at the
    zip code level
  • Composite SES (socioeconomic status) that
    summed the normal scores of the above three
    variables that were equally weighted and
    categorized the total scores into quartiles

10
Treatment
  • Primary Treatment
  • radical prostatectomy, or
  • radiation therapy, or
  • watchful waiting (observational management)
  • all standard of care (for local stage tumor).
  • Adjuvant therapy
  • hormonal therapy and
  • chemotherapy
  • efficacy not confirmed in RCTs.

11
Figure 1. Kaplan-Meier survival curve by 3 ethnic
groups
12
Table 1. Comparison of age among 3 racial/ethnic
groups
Age (years) Caucasians Caucasians African Americans African Americans Hispanics Hispanics
n n n
Median age (range) 73 (65-103) 73 (65-103) 72 (65-103) 72 (65-103) 71 (65-101) 71 (65-101)
65-69 15,416 28.7 2,131 33.7 411 36.0
70-74 17,324 32.2 2,023 32.0 390 34.1
75-79 12,271 22.8 1,314 20.8 221 19.3
80 8,753 16.3 853 13.5 121 10.6
Total 53,764 100.0 6,321 100.0 1,143 100.0
13
Table 2. Comparison of tumor grades among 3
racial/ethnic groups
Gleason Score Caucasians Caucasians African Americans African Americans Hispanics Hispanics
n n n
2-4 7,475 13.9 740 11.7 198 17.3
5-7 33,218 61.8 3,789 59.9 650 56.9
8-10 10,438 19.4 1,410 22.3 240 21.0
u/k 2,633 4.9 382 6.0 55 4.8
14
Table 3. Comparison of comorbidity among 3
racial/ethnic groups
Comorbidity Scores Caucasians Caucasians African Americans African Americans Hispanics Hispanics
n n n
0 34,402 64.0 3,394 53.7 669 58.5
1 12,565 23.4 1,611 25.5 290 25.4
2 4,342 8.1 747 11.8 96 8.4
gt3 2,455 4.6 569 9.0 88 7.7
15
Table 4. Comparison of treatment among 3
racial/ethnic groups
Surgery and Caucasians Caucasians African Am African Am Hispanics Hispanics
Radiation n n n
Prostatectomy 12,907 24.0 1,070 16.9 328 28.7
Radiation 20,536 38.2 2,463 39.0 327 28.6
Both 1,205 2.2 89 1.4 26 2.3
Watchful Waiting 19,116 35.6 2,699 42.7 462 40.4
Chemotherapy
No 44,219 82.3 5,345 84.6 861 75.3
Yes 9,545 17.8 976 15.4 282 24.7
Hormone
No 39,266 73.0 4,808 76.1 815 71.3
Yes 14,498 27.0 1,513 23.9 328 28.7
16
Table 5. Comparison of socioeconomic status (SES)
among 3 ethnic groups
Poverty Caucasians Caucasians African Am African Am Hispanics Hispanics
(quartiles) n n n
1st 14,861 27.6 267 4.2 69 6.0
2nd 14,429 26.8 529 8.4 132 11.6
3rd 13,974 26.0 838 13.3 208 18.2
4th 9,603 17.9 4639 73.4 693 60.6
Missing 897 1.7 48 0.8 41 3.6
Total 53,764 100.0 6,321 100.0 1,143 100.0
17
Table 8. Comparison of socioeconomic status (SES)
among 3 ethnic groups
Composite SES (quartile) Caucasians Caucasians African Am African Am Hispanics Hispanics
(high to low) n n n
1st (High SES) 14059 26.2 204 3.2 56 4.9
2nd 13732 25.5 460 7.3 121 10.6
3rd 13199 24.6 914 14.5 199 17.4
4th (Low SES) 9128 17.0 4528 71.6 661 57.8
Missing 3646 6.8 215 3.4 106 9.3
Total 53764 100.0 6321 100.0 1143 100.0
18
Table 9. Observed survival rate by ethnicity and
socioeconomic status
Race/ethnicity and SES 3-year survival () (cases in 1992-1999) 3-year survival () (cases in 1992-1999) 5-year survival () (cases in 1992-1997) 5-year survival () (cases in 1992-1997) 10-year survival () (cases in 1992-1993) 10-year survival () (cases in 1992-1993)
All-cause Disease-specific All-cause Disease-specific All-cause Disease-specific
Ethnic Groups
Caucasians 87.8 98.2 78.0 96.4 52.6 94.0
African Am 84.1 97.5 72.6 95.3 43.3 91.1
Hispanics 91.0 98.9 83.5 97.3 61.3 95.6
Composite SES
1st 90.6 98.7 82.5 97.2 58.6 94.9
2nd 88.3 98.1 79.1 96.3 53.9 93.9
3rd 86.9 98.3 76.4 96.3 50.5 94.0
4th 84.0 97.5 72.1 95.4 44.1 92.0
Total 87.5 98.2 77.5 96.3 51.9 93.7
unadjusted
19
Table 10. Hazard ratio of mortality by
socioeconomic status
SES Hazard ratio (95 CI) of mortality Hazard ratio (95 CI) of mortality Hazard ratio (95 CI) of mortality Hazard ratio (95 CI) of mortality Hazard ratio (95 CI) of mortality
(high to low) All-cause mortality All-cause mortality CA-specific mortality CA-specific mortality
Model 1 Model 2 Model 3 Model 4
Composite SES
1st (High SES) 1.0 (ref) 1.0 (ref) 1.0 (ref) 1.0 (ref)
2nd 1.11 (1.07-1.16) 1.11 (1.07-1.16) 1.26 (1.09-1.44) 1.25 (1.09-1.44)
3rd 1.22 (1.17-1.27) 1.22 (1.17-1.27) 1.24 (1.07-1.43) 1.22 (1.05-1.41)
4th (Low SES) 1.31 (1.25-1.36) 1.31 (1.25-1.37) 1.48 (1.28-1.70) 1.40 (1.20-1.64)
Models 1 3 adjusted for age, comorbidity, AJCC-stage, Gleason score, year of diagnosis, SEER region, and treatment. Models 1 3 adjusted for age, comorbidity, AJCC-stage, Gleason score, year of diagnosis, SEER region, and treatment. Models 1 3 adjusted for age, comorbidity, AJCC-stage, Gleason score, year of diagnosis, SEER region, and treatment. Models 1 3 adjusted for age, comorbidity, AJCC-stage, Gleason score, year of diagnosis, SEER region, and treatment. Models 1 3 adjusted for age, comorbidity, AJCC-stage, Gleason score, year of diagnosis, SEER region, and treatment. Models 1 3 adjusted for age, comorbidity, AJCC-stage, Gleason score, year of diagnosis, SEER region, and treatment.
Models 2 4 adjusted for race/ethnicity, in addition to factors in Models 1 3. Models 2 4 adjusted for race/ethnicity, in addition to factors in Models 1 3. Models 2 4 adjusted for race/ethnicity, in addition to factors in Models 1 3. Models 2 4 adjusted for race/ethnicity, in addition to factors in Models 1 3. Models 2 4 adjusted for race/ethnicity, in addition to factors in Models 1 3. Models 2 4 adjusted for race/ethnicity, in addition to factors in Models 1 3.
20
Table 12. Hazard ratio of mortality by Poverty
SES Hazard ratio (95 CI) of mortality Hazard ratio (95 CI) of mortality Hazard ratio (95 CI) of mortality Hazard ratio (95 CI) of mortality Hazard ratio (95 CI) of mortality
All-cause mortality All-cause mortality CA-specific mortality CA-specific mortality
Model 1 Model 2 Model 3 Model 4
Poverty
1st 1.0 1.0 1.0 1.0
2nd 1.11 (1.06-1.15) 1.11 (1.06-1.15) 1.17 (1.02-1.33) 1.15 (1.01-1.32)
3rd 1.19 (1.14-1.24) 1.19 (1.14-1.24) 1.12 (0.97-1.30) 1.11 (0.96-1.28)
4th 1.28 (1.23-1.34) 1.28 (1.22-1.34) 1.36 (1.18-1.55) 1.31 (1.13-1.52)
Models 1 3 adjusted for age, comorbidity, AJCC-stage, Gleason score, year of diagnosis, SEER region, and treatment Models 1 3 adjusted for age, comorbidity, AJCC-stage, Gleason score, year of diagnosis, SEER region, and treatment Models 1 3 adjusted for age, comorbidity, AJCC-stage, Gleason score, year of diagnosis, SEER region, and treatment Models 1 3 adjusted for age, comorbidity, AJCC-stage, Gleason score, year of diagnosis, SEER region, and treatment Models 1 3 adjusted for age, comorbidity, AJCC-stage, Gleason score, year of diagnosis, SEER region, and treatment Models 1 3 adjusted for age, comorbidity, AJCC-stage, Gleason score, year of diagnosis, SEER region, and treatment
Models 2 4 adjusted for ethnicity, in addition to factors in Models 1 3. Models 2 4 adjusted for ethnicity, in addition to factors in Models 1 3. Models 2 4 adjusted for ethnicity, in addition to factors in Models 1 3. Models 2 4 adjusted for ethnicity, in addition to factors in Models 1 3. Models 2 4 adjusted for ethnicity, in addition to factors in Models 1 3. Models 2 4 adjusted for ethnicity, in addition to factors in Models 1 3.
21
Table 17. Hazard ratio of mortality by
race/ethnicity
Race/ Hazard ratio (95 CI) of mortality Hazard ratio (95 CI) of mortality Hazard ratio (95 CI) of mortality Hazard ratio (95 CI) of mortality Hazard ratio (95 CI) of mortality
ethnicity All-cause mortality All-cause mortality CA-specific mortality CA-specific mortality
Model 1 Model 2 Model 3 Model 4
Caucasians 1.00 1.00 1.00 1.00
African Am 1.14 (1.09-1.19) 1.01 (0.97-1.06) 1.33 (1.16-1.53) 1.17 (0.99-1.37)
Hispanics 0.85 (0.76-0.94) 0.78 (0.70-0.87) 0.84 (0.57-1.24) 0.78 (0.53-1.16)
Models 1 3 - Adjusted for age, comorbidity, AJCC stage, Gleason score, year of diagnosis, SEER region, and treatment. Models 1 3 - Adjusted for age, comorbidity, AJCC stage, Gleason score, year of diagnosis, SEER region, and treatment. Models 1 3 - Adjusted for age, comorbidity, AJCC stage, Gleason score, year of diagnosis, SEER region, and treatment. Models 1 3 - Adjusted for age, comorbidity, AJCC stage, Gleason score, year of diagnosis, SEER region, and treatment. Models 1 3 - Adjusted for age, comorbidity, AJCC stage, Gleason score, year of diagnosis, SEER region, and treatment. Models 1 3 - Adjusted for age, comorbidity, AJCC stage, Gleason score, year of diagnosis, SEER region, and treatment.
Models 2 4 - Adjusted for composite SES, in addition to above factors. Models 2 4 - Adjusted for composite SES, in addition to above factors. Models 2 4 - Adjusted for composite SES, in addition to above factors. Models 2 4 - Adjusted for composite SES, in addition to above factors. Models 2 4 - Adjusted for composite SES, in addition to above factors. Models 2 4 - Adjusted for composite SES, in addition to above factors.
22
Further Analysis
  • Apart from composite SES, the similar results
    were achieved by controlling for education,
    poverty, and income.
  • There was no significant interaction between
    race/ethnicity and socioeconomic status.

23
Conclusions and public health implications
  • Racial disparity in survival among men with
    locoregional prostate cancer was largely
    explained by their socioeconomic status.
  • Lower socioeconomic status appeared to be one of
    the major barriers to achieving comparable
    outcomes for men with prostate cancer.
  • Important public health implications if we are to
    achieve the goals of Healthy People 2010, one of
    which is to eliminate health disparities.

24
Strengths
  • Large population-based cohort study, covering all
    (gt98) incident cases of prostate Ca,
    pathologically confirmed by the 11 SEER
    registries.
  • Reliable information on cancer stage, grade,
    primary therapy (surgery and radiation), and
    long-term follow-up on vital status.
  • Linked with Medicare claims, providing important
    data on comorbidity a strong confounder of
    survival.
  • Adjuvant chemotherapy and hormonal therapy data
    can be uniquely identified from Medicare claims.
  • Several measures of SES variables ? consistent
    findings.

25
Limitations
  • SES at the level of census tract may be imperfect
    proxy measure for individual SES ? ecological
    fallacy, but studies showed individual and
    community level SESs in good agreement
  • Local-regional stage ? Residual confounding (even
    after adjusting for AJCC stage and tumor grade
    etc.)
  • Hispanic Paradox low SES and RFs for
    mortality but has mortality advantage
  • Lack of info. on providers (physicians and
    hospitals), on patient/physician preference on
    the choice of the therapy, and on PSA screening
    and surveillance
  • Men age 65 or older, and in 11 SEER areas ?
    Generalizability to younger men and other regions
    or country?

26
Questions/Comments
  • Thanks for your attention!
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