Prostate Cancer Outcomes by Race

1
Prostate Cancer Outcomes by Race Treatment Site

• Can-lan Sun MD PhD, Smita Bhatia MD MPH, Lennie
  Wong PhD, Gail Washington DNS, Karen
  Nielsen-Menicucci PhD
• 12/11/2008

2
2008 Estimated US Cancer Deaths
Men294,120
Lung bronchus 31
Prostate 10
Colon rectum 8
Pancreas 6
Liver intrahepatic bile duct 4
Leukemia 4
Esophagus 4
Urinary bladder 3
Non-Hodgkin lymphoma 3
Kidney renal pelvis 3
All other sites 24
ONSOther nervous system. Source American Cancer
Society, 2008.
3
Cancer Death Rates by Sex, US, 1975-2004
Rate Per 100,000
Men
Both Sexes
Women
Age-adjusted to the 2000 US standard
population. Source Surveillance, Epidemiology,
and End Results (SEER) Program (www.seer.cancer.go
v) SEERStat Database Mortality - All COD,
Public-Use With State, Total U.S. (1969-2004),
National Cancer Institute, DCCPS, Surveillance
Research Program, Cancer Statistics Branch,
released April 2007. Underlying mortality data
provided by NCHS (www.cdc.gov/nchs).
4
Cancer Death Rates Among Men, US,1930-2004
Rate Per 100,000
Prostate
Age-adjusted to the 2000 US standard
population. Source US Mortality Data 1960-2004,
US Mortality Volumes 1930-1959, National Center
for Health Statistics, Centers for Disease
Control and Prevention, 2006.
5
Prostate Cancer Mortality Rates in the US,
1969-2004
6
African Americans are twice as likely than Whites
to die of prostate cancer.
Prostate Cancer Death Rates, 2005 Per 100,000
population
White, Non-Hispanic
Hispanic
Deaths
African American, Non-Hispanic
Asian and Pacific Islander
American Indian/Alaska Native
6
Note Data are age adjusted to the 2000 standard
population. SOURCE National Cancer Institute,
Surveillence, Epidemiology, and End Results
(SEER) Program National Vital Statistics
System--Mortality, NCHS, CDC.
7
Why?

• More aggressive tumors
• More advanced stage at diagnosis
• Health insurance and access to care
• Difference in screening-early detection
• Differences in receiving optimal treatment
• Socioeconomic status
• Healthcare provider

8
Aims

• Aim 1 Compare mortality rates between
  African-Americans and Caucasians with newly
  diagnosed prostate cancer in Los Angeles County
  after controlling for age, SES, marital status,
  stage, grade, insurance, and treatment modality.
• Aim 2 Compare the mortality rates for prostate
  cancer between NCI designated comprehensive
  cancer centers and other treatment facilities in
  Los Angeles County.
• Aim 3 Compare the mortality rates by race for
  patients with prostate cancer receiving care
  within NCI cancer centers
• Aim 4 Describe the proportion of
  African-Americans and Caucasians seeking
  treatment for newly diagnosed prostate cancer at
  NCI designated cancer centers and other treatment
  facilities, and understand the role of
  socioeconomic and insurance status in accessing
  care at the NCI-designated cancer centers versus
  other treatment facilities

9
Data Sources

• Los Angeles Cancer Surveillance Program (CSP)
• White or African-American
• Diagnosed with prostate cancer 1998-2003
• NCI-designated Cancer Center
• USC-Norris Cancer Center, UCLA-Jonsson Cancer
  Center, City of Hope Cancer Center
• Office of State Health Planning Department
  (OSHPD)
• Teaching status
• Bed Size
• Average length of stay
• Urban vs. Rural
• Hospital in-patient racial distribution
• MSSA below poverty, racial distribution

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Variables

• Outcomes
• Overall mortality
• Prostate cancer-specific mortality
• Time to event (in years from the date of
  diagnosis to date of death or last known date)
• Main Exposure
• Race White vs. African-American
• NCI designated Cancer Center vs. other non-NCI
  designated treatment facilities

11
Variables

• Adjustment variables
• Demographics
• SES, age, marital status
• Year of diagnosis 1998-2003
• Insurance
• Tumor information
• Stage (localized, regional, distant)
• Grade (well-differentiated, moderately
  differentiated, poor/undifferentiated)
• Treatment information
• Surgery (no, radical/total prostatectomy)
• Radiation (yes, no)
• Hormone therapy (yes, no)

12
Preliminary Results
24,360
22886
21426
19817
19309
19298
18984
18,790
13
Comparison White vs. AA
White N14, 579 AA N4211
Alive 11856 (81) 3328 (79)
Dead 2723 (19) 883 (21)
prostate-specific 543 (4) 200 (5)
other 2180 (15) 683 (16)
P lt0.05
14
Comparison White vs. AA
White AA
Age at Dx 68 (16-99) 64 (33-93)
Stage
Local 12831 (88.0) 3708 (88.1)
Regional 1290 (8.9)) 286 (6.8)
Distant 458 (3.1) 217 (5.1)
Grade
Well-differentiated 525 (3.6) 151 (3.6)
Moderately differentiated 10932 (75.0) 3177 (75.4)
Poor/undifferentiated 3122 (21.4) 883 (21.0)
Plt0.05
15
Comparison White vs. AA
White AA
Treatment
Watchful waiting 2284 (15.7) 925 (20.0)
Surgery only 5419 (37.2) 1420 (33.7)
Hormone only 1759 (12.1) 561 (13.3)
Radiation only 2371 (16.2) 691 (16.4)
Combination of Surgery /hormone /radiation 2746 (18.8) 614 (14.6)
Plt0.05
16
Comparison White vs. AA
White AA
SES
1 (highest) 6499 (44.6) 568 (13.5)
2 3667 (25.1) 719 (17.1)
3 2464 (16.9) 897 (21.3)
4 1383 (9.5) 1072 (25.4)
5 (lowest) 566 (3.9) 955 (22.7)
Plt0.05
17
Comparison White vs. AA
White AA
Insurance
no 211 (1.5) 195 (4.6)
Insurance NOS 806 (5.5) 144 (3.4)
Managed care, HMO PPO 7977 (54.7) 2329 (55.3)
Medicare 2781 (19.1) 439 (10.4)
Military, Veterinarian, PHS 290 (2.0) 251 (6.0)
County funded 2514 (17.2) 853 (20.3)
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Specific Aim 1

• Compare mortality rates between African-Americans
  and Caucasians with newly diagnosed prostate
  cancer in Los Angeles County

19
Prostate-specific P0.002
Overall Mortality Plt0.001
20
Specific Aim 2

• Compare the mortality rates for prostate cancer
  between NCI-designated Cancer Centers and other
  treatment facilities in Los Angeles County

21
Prostate-specific Plt0.001
Overall mortality Plt0.001
22
Specific Aim 3

• Compare the mortality rates by race for patients
  with prostate cancer receiving care within
  NCI-designated Cancer Centers

23
Prostate-specific P0.52
Overall Mortality P0.17
24
Multivariate analysis

• Aim 1 Compare mortality rates between
  African-Americans and Caucasians with newly
  diagnosed prostate cancer in Los Angeles County
  after controlling for age, SES, stage, grade,
  insurance, and treatment modality.

25
Overall mortality AA vs. White
26
Prostate-specific mortality AA vs. White
27
Multivariate analysis

• Aim 2 Compare mortality rates for prostate
  cancer between NCI designated comprehensive
  cancer centers and other treatment facilities in
  Los Angeles County.

28
Overall mortality NCI vs. non-NCI
29
Prostate-specific mortality NCI vs. non-NCI
30
Multivariate analysis

• Aim 3 Compare mortality rates by race for
  patients with prostate cancer receiving care
  within NCI-designated Cancer Centers
• Due to the small number of AA receiving care at
  NCI-designated cancer centers, we were unable to
  perform this analysis.

31
Specific Aim 4

• Aim 4 Understand the role of sociodemographic
  factors in accessing care at the NCI-designated
  treatment centers versus non-NCI centers

32
Utilization of NCI-designated Cancer Center
Non-NCI NCI OR
Race
White 12933 (88.7) 1646 (11.3) 1.00
AA 4063 (96.5) 148 (3.5) 0.29 (0.24-0.34)
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Utilization of NCI Cancer Centers AA vs. White
34
Utilization of NCI-designated Cancer Center
OR (95 CI)
AA vs. White 0.42 (0.35-0.50)

Age at diagnosis (years) 0.95 (0.94-0.95)
SES 1 highest
SES 2 0.61 (0.53-0.69)
SES 3 0.41 (0.35-0.49)
SES 4 0.37 (0.30-0.46)
SES 5 lowest 0.30 (0.22-0.42)
Insurance no 1.00
Insurance NOS 2.55 (1.58-4.12)
Managed care HMO PPO 1.05 (0.67-1.66)
Medicare 3.22 (2.01-5.13)
County 0.08 (0.02-0.34)
Military/veteran/ PHS 2.12 (1.32-3.40)
35
Utilization of NCI-designated Cancer Center
OR (95 CI)
Grade well-differentiated 1.00
Moderately differentiated 3.11 (1.87-5.18)
Poor/undifferentiated 3.79 (2.25-6.36)
Stage localized 1.00
Regional 1.29 (1.10-1.51)
Distant 1.12 (0.75-1.65)
Treatment watchful waiting 1.00
Surgery only 2.65 (2.16-3.25)
Hormone only 0.80 (0.59-1.09)
Radiation only 1.04 (0.81-1.33)
Multiple 1.36 (1.09-1.70)
Year of Dx (more recent years) 1.06 (1.03-1.10)
36
Conclusion

• AA have a higher overall and prostate-specific
  mortality on univariate analysis
• AA have comparable overall and prostate specific
  mortality to Whites after adjustment for
  sociodemographic factors, tumor characteristic,
  treatment modality, and treatment site
• NCI-designated cancer centers have lower overall
  and prostate specific mortality compared to
  non-NCI treatment facilities
• This difference persists after adjustment for all
  clinical and sociodemographic factors
• Within NCI-designated cancer centers, AA have
  comparable overall and prostate-specific
  mortality to Whites
• Within the constraints of the limited sample size
• AA are less likely to use NCI-designated Cancer
  Centers
• Independent of SES, insurance, and tumor factors

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Future Plans (Year 02)

• Current data set demonstrates that only 148 AA
  utilized the 3 NCI-designated Cancer Centers in
  LAC
• Expand the scope of analysis
• Obtain data from CSP for 1976 to 2003
• Explore the reasons of inferior outcomes at
  non-NCI designated Cancer Centers
• Data from Office of Statewide Health Planning and
  Development.
• Secondary quality indicators
• Teaching status, bed size, hospital in-patient
  average stay, MSSA poverty, racial distribution,

38
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39
Thank you!
40
Does Treatment Site really make a difference?

• In-hospital short-term mortality after
  Prostatectomy
• High volume of prostectomies associated with low
  mortality
• Medicare claims data
• n101,604 between 1991 and 1994
• Nationwide Inpatient Sample
• n66,693 between 1989-1995

Ellison, L.M., J.A. Heaney, and J.D. Birkmeyer,
The effect of hospital volume on mortality and
resource use after radical prostatectomy. J Urol,
2000. 163(3) p. 867-9.
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.
41
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

42
NCI-Designation

• Medicare database
• Mortality after cystectomy, colectomy, pulmonary
  resections, pancreatic resection, gastrectomy and
  esophagectomy
• NCI Centers had lower operative mortality in 4/6
  procedures
• Long term mortality no difference

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.
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Overall HR Prostate-specific HR
AA vs. White 1.08 (0.99-1.17) 1.12 (0.93-1.35)
NCI center vs. non-NCI 0.75 (0.64-0.88) 0.69 (0.49-0.97)
Age at diagnosis (years) 1.05 (1.04-1.06) 1.02 (1.01-1.03)
SES 1 highest 1.00 1.00
SES 2 1.21 (1.10-1.33) 1.08 (0.87-1.33)
SES 3 1.33 (1.21-1.47) 1.26 (1.02-1.55)
SES 4 1.37 (1.23-1.52) 1.15 (0.91-1.46)
SES 5 lowest 1.46 (1.29-1.66) 1.29 (0.99-1.68)
No Insurance 1.00
Insurance NOS 0.53 (0.39-0.71) 0.46 (0.25-0.84)
HMO PPO 0.84 (0.67-1.05) 0.91 (0.60-1.39)
Medicare 0.86 (0.68-1.08) 0.82 (0.53-1.28)
Military/Vet/ Indian/PHS 0.80 (0.61-1.06) 0.70 (0.40-1.22)
County funded 0.82 (0.65-1.03) 0.74 (0.48-1.15)
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Overall HR Prostate-specific HR
Grade well-differentiated 1.00 1.00
Moderately differentiated 1.08 (0.91-1.28) 1.68 (0.91-3.07)
Poor/undifferentiated 1.69 (1.42-2.01) 4.87 (2.66-8.92)
Stage localized 1.00 1.00
Regional 1.25 (1.07-1.38) 2.28 (1.76-2.94)
Distant 3.76 (3.38-4.18) 14.72 (12.21-17.76)
Treatment watchful waiting 1.00
Surgery only 0.31 (0.28-0.35) 0.19 (0.13-0.27)
Hormone only 1.04 (0.95-1.15) 1.29 (1.05-1.60)
Radiation only 0.61 (0.55-0.68) 0.50 (0.36-0.70)
Multiple 0.67 (0.60-0.74) 0.86 (0.67-1.09)
Year of Dx 1.03 (1.01-1.06) 0.98 (0.93-1.03)