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

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 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

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 raceand 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 (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

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.