Getting back to equal: The influence of insurance status on racial disparities in the treatment of African American men with high-risk prostate cancer

Prostate cancer outcomes for men aged younger than 65 years with Medicaid versus private insurance

BACKGROUND

In the current national debate regarding private insurance versus Medicaid expansion, understanding how insurance is associated with racial disparities in prostate cancer (CaP) outcomes has broad policy implications. In the current study, the authors examined the association between insurance status, race, and CaP outcomes.

METHODS

The Surveillance, Epidemiology, and End Results program identified 155,524 men aged < 65 years who were diagnosed with CaP from 2007 through 2014. The association between insurance and stage of disease at the time of presentation was examined. Among men with localized CaP, the associations between insurance and receipt of therapy and prostate cancer-specific mortality (PCSM) were determined.

RESULTS

Compared with private insurance, men with Medicaid were more likely to present with metastatic disease (adjusted odds ratio [AOR], 4.27; 95% confidence interval [95% CI], 4.01-4.55), were less likely to receive definitive treatment (AOR, 0.67; 95% CI, 0.62-0.71), and had increased PCSM (adjusted hazard ratio, 1.83; 95% CI, 1.50-2.24), regardless of race. Significant interactions between race and insurance status indicated that insurance had more than an additive association with race. Among privately insured patients, disparities in PCSM (AOR, 1.2; 95% CI, 1.03-1.40 [P = .019]) and presentation with metastatic disease (AOR, 1.13; 95% CI, 1.06-1.21 [P<.001]) were observed. No disparities were observed among patients with Medicaid insurance with regard to PCSM (AOR, 0.79; 95% CI, 0.52-1.20 [P = .272]) and metastatic disease (AOR, 0.91; 95% CI, 0.80-1.03 [P = .139]).

CONCLUSIONS

Racial disparities in the outcomes of patients with CaP were observed in privately insured cohorts, whereas these disparities appeared to be reduced among patients with Medicaid insurance. However, outcomes need to be improved overall. Whether the equality in outcomes for Medicaid is due to white and African American patients doing "equally poorly" or "equally well" is unclear. Cancer 2018;124:752-9. © 2017 American Cancer Society.

Understanding PSA and its derivatives in prediction of tumor volume: Addressing health disparities in prostate cancer risk stratification

Objectives

To address health disparities in risk stratification of U.S. Hispanic/Latino men by characterizing influences of prostate weight, body mass index, and race/ethnicity on the correlation of PSA derivatives with Gleason score 6 (Grade Group 1) tumor volume in a diverse cohort.

Results

Using published PSA density and PSA mass density cutoff values, men with higher body mass indices and prostate weights were less likely to have a tumor volume <0.5 cm³. Variability across race/ethnicity was found in the univariable analysis for all PSA derivatives when predicting for tumor volume. In receiver operator characteristic analysis, area under the curve values for all PSA derivatives varied across race/ethnicity with lower optimal cutoff values for Hispanic/Latino (PSA=2.79, PSA density=0.06, PSA mass=0.37, PSA mass density=0.011) and Non-Hispanic Black (PSA=3.75, PSA density=0.07, PSA mass=0.46, PSA mass density=0.008) compared to Non-Hispanic White men (PSA=4.20, PSA density=0.11 PSA mass=0.53, PSA mass density=0.014).

Materials and Methods

We retrospectively analyzed 589 patients with low-risk prostate cancer at radical prostatectomy. Pre-operative PSA, patient height, body weight, and prostate weight were used to calculate all PSA derivatives. Receiver operating characteristic curves were constructed for each PSA derivative per racial/ethnic group to establish optimal cutoff values predicting for tumor volume ≥0.5 cm³.

Conclusions

Increasing prostate weight and body mass index negatively influence PSA derivatives for predicting tumor volume. PSA derivatives’ ability to predict tumor volume varies significantly across race/ethnicity. Hispanic/Latino and Non-Hispanic Black men have lower optimal cutoff values for all PSA derivatives, which may impact risk assessment for prostate cancer.

Ethnic heterogeneity and prostate cancer mortality in Hispanic/Latino men: a population-based study

BACKGROUND

Few studies focus on prostate cancer (PCa) outcomes in Hispanic/Latino men. Our study explores whether Hispanic/Latino subgroups demonstrate significantly different prostate cancer-specific mortality (PCSM) relative to Non-Hispanic White (NHW) and Non-Hispanic Black (NHB) men.

METHODS

We extracted a population-based cohort of men diagnosed with local-regional PCa from 2000-2013 (n= 486,865). PCSM was measured in racial/ethnic groups: NHW (n=352,886), NHB (n= 70,983), Hispanic/Latino (n= 40,462), and Asian American/Pacific Islander (n= 22,534). PCSM was also measured in Hispanic/Latino subgroups: Mexican (n= 8,077), Puerto Rican (n= 1,284), South or Central American (n= 3,021), Cuban (n= 788), and Dominican (n= 300). We conducted univariable and multivariable analyses (MVA) to compare risk for PCSM.

RESULTS

Compared to NHW men, results showed worse outcomes for NHB men with similar outcomes for Hispanic/Latino men. In MVA with NHW men as a reference, NHB (HR= 1.15, p <0.001) men had significantly worse PCSM and Hispanic/Latino (HR= 1.02, p= 0.534) men did not show a significant difference. In a second MVA, Puerto Rican (HR= 1.71, p <0.001) and Mexican (HR= 1.21, p= 0.008) men had significantly higher PCSM. With NHB men as a reference, the MVA showed Puerto Rican (HR= 1.50, p= 0.006) men with higher PCSM and Mexican (HR= 1.08, p= 0.307) men with no significant difference.

CONCLUSIONS

Our findings indicate previously unknown disparities in PCSM for Puerto Rican and Mexican American men.

African-American Prostate Cancer Disparities

PURPOSE OF REVIEW

The purpose of this review is to examine prostate cancer racial disparities specific to the African-American population.

RECENT FINDINGS

African-American men are more likely to be diagnosed with prostate cancer, present at an earlier age; are more likely to have locally advanced or metastatic disease at diagnosis; and have suboptimal outcomes to standard treatments. Prostate cancer treatment requires a nuanced approach, particularly when applying screening, counseling, and management of African-American men. Oncological as well as functional outcomes may differ and are potentially due to a combination of genetic, molecular, behavioral, and socioeconomic factors.

Race Does Not Affect Tumor Control, Adverse Effects, or Quality of Life after Proton Therapy

Purpose

To compare 5-year biochemical control, toxicity, and patient-reported quality of life (QOL) outcomes for African American and White patients treated with proton therapy (PT) for prostate cancer.

Materials and Methods

We reviewed the medical records of 1,066 men with clinically localized prostate cancer. Patients were treated with definitive PT between 2006 and 2010. Patients received a median radiation dose of 78 Gy (RBE) with conventional fractionation (1.8- 2 Gy [RBE] per fraction). Sixty-eight (6.4%) men self-identified as African American and 998 (93.6%) self-identified as White. Five-year rates of biochemical control, grade 3 genitourinary and gastrointestinal toxicity, and patient-reported QOL are reported and compared between African American and White patients.

Results

Median biochemical follow-up was 5.0 years for both African American and White patients. Median follow-up for toxicity was 5.0 and 5.2 years, respectively. On multivariate analysis, race was not a significant predictor for 5-year freedom from biochemical failure (HR 0.8, p=0.55). No significant association was found between race and grade 3 genitourinary toxicity on multivariate analysis at 5 years (HR 2.5, p=0.10). Patient-reported QOL using median EPIC bowel, urinary incontinence, and irritative summaries scores were not significantly different between the groups. African Americans had higher median sexual summary scores at 2 years than White patients (75 vs. 54, p=0.01) but by 5+ years, the sexual summary scores were no longer significantly different (63 vs. 53, p=0.35).

Conclusion

With a median follow-up of 5 years, there were no racial disparities in biochemical control, grade 3 toxicity, or patient-reported QOL after PT for prostate cancer.

Treatment of men with high-risk prostate cancer based on race, insurance coverage, and access to advanced technology

PURPOSE

We characterized factors related to nondefinitive management (NDM) of patients with high-risk prostate cancer and assessed impact from race, insurance status, and facility-level volume of technologically advanced prostate cancer treatments (i.e., intensity-modulated radiation therapy, robotic-assisted laparoscopic radical prostatectomy) on this outcome.

METHODS

We identified men with high-risk localized prostate cancer (based on D׳Amico criteria) in the National Cancer Database (2010-2012). Primary outcome was NDM (i.e., delayed/no treatment with prostatectomy/radiation therapy or androgen-deprivation monotherapy). Treating facilities were classified by quartiles of proportions of patients treated with advanced technology. Multivariable regression estimated odds of primary outcome based on race, insurance status, and facility-level technology use, and evaluated for interactions between these covariates.

RESULTS

Among 60,300 patients, 9,265 (15.4%) received NDM. This was more common among non-White men (P<0.001), Medicaid/uninsured patients (P<0.001), and those managed at facilities in the lowest quartile of technology use (25.1% vs. 11.0% highest, P<0.001). Though NDM was common among non-White men with Medicaid/no insurance treated at low-technology centers (43% vs. 10% White, private/Medicare, high-tech facility; adjusted odds ratios = 7.18, P<0.001), this was less likely if this group was managed at a high-tech hospital (22% vs. 43% low-tech, P<0.001).

CONCLUSIONS

Technology use at a facility correlates with high-quality prostate cancer care and is associated with diminished disparities based on insurance status and patient race. More research is required to characterize other facility-level factors explaining these findings.

Population-Based External Validation of the Updated 2012 Partin Tables in Contemporary North American Prostate Cancer Patients

OBJECTIVE

To externally validate the updated 2012 Partin Tables in contemporary North American patients treated with radical prostatectomy (RP) for localized prostate cancer (PCa) at community institutions.

MATERIALS AND METHODS

We examined records of 25,254 patients treated with RP and pelvic lymph node dissection (PLND) between 2010 and 2013, within the surveillance, epidemiology, and end results database. The ROC derived AUC assessed discriminant properties of the updated 2012 Partin Tables of organ confined disease (OC), extracapsular extension (ECE), seminal vesical invasion (SVI), and lymph node invasion (LNI). Calibration plots focused on calibration between predicted and observed rates.

RESULTS

Proportions of OC, ECE, SVI, and LNI at RP were 69.8%, 18.4%, 7.4%, and 4.4%, respectively. Accuracy for prediction of OC, ECE, SVI, and LNI was 70.4%, 59.9%, 72.9%, and 77.1%, respectively. In subgroup analyses in patients with nodal yield >10, accuracy for LNI prediction was 76.0%. Subgroup analyses in elderly patients and in African American patients revealed decreased accuracy for prediction of all four endpoints. Last but not least, SVI and LNI calibration plots showed excellent agreement, versus good agreement for OC (maximum underestimation of 10%) and poor agreement for ECE (maximum overestimation of 12%).

CONCLUSION

Taken together, the updated 2012 Partin Tables can be unequivocally endorsed for prediction of OC, SVI, and LNI in community-based patients with localized PCa. Conversely, ECE predictions failed to reach the minimum accuracy requirements of 70%. Prostate 77:105-113, 2017. © 2016 Wiley Periodicals, Inc.

Racial Differences in the Diagnosis and Treatment of Prostate Cancer

Disparities between African American and Caucasian men in prostate cancer (PCa) diagnosis and treatment in the United States have been well established, with significant racial disparities documented at all stages of PCa management, from differences in the type of treatment offered to progression-free survival or death. These disparities appear to be complex in nature, involving biological determinants as well as socioeconomic and cultural aspects. We present a review of the literature on racial disparities in the diagnosis of PCa, treatment, survival, and genetic susceptibility. Significant differences were found among African Americans and whites in the incidence and mortality rates; namely, African Americans are diagnosed with PCa at younger ages than whites and usually with more advanced stages of the disease, and also undergo prostate-specific antigen testing less frequently. However, the determinants of the high rate of incidence and aggressiveness of PCa in African Americans remain unresolved. This pattern can be attributed to socioeconomic status, detection occurring at advanced stages of the disease, biological aggressiveness, family history, and differences in genetic susceptibility. Another risk factor for PCa is obesity. We found many discrepancies regarding treatment, including a tendency for more African American patients to be in watchful waiting than whites. Many factors are responsible for the higher incidence and mortality rates in African Americans. Better screening, improved access to health insurance and clinics, and more homogeneous forms of treatment will contribute to the reduction of disparities between African Americans and white men in PCa incidence and mortality.

Disparities in Treatment of Patients With High-risk Prostate Cancer: Results From a Population-based Cohort

OBJECTIVE

To assess the variation in primary treatment of high-risk prostate cancer (PCa) by different hospital characteristics in the United States.

MATERIALS AND METHODS

We used the National Cancer Data Base to identify patients diagnosed with pretreatment high-risk PCa from 2004 to 2011. The primary outcomes were different forms of primary therapy or watchful waiting (WW) across different types of hospitals (community, comprehensive cancer community, and academic hospitals). Multivariable logistic regression analyses were used to test for differences in treatment by hospital type.

RESULTS

During the study period, we identified 102,701 men diagnosed with high-risk PCa. Overall, the most common treatment was radical prostatectomy (37.0%) followed by radiation therapy (33.2%) and WW (8.5%). Compared with white men with high-risk PCa, black men had lower adjusted odds ratios (OR) for surgery at comprehensive community (OR: 0.64; P <.001) and academic (OR: 0.62; P <.001) hospitals. Similarly, black men were also more likely to be managed with WW at community (OR: 1.49; P <.001), comprehensive cancer community (OR: 1.24; P <.001), and academic (OR: 1.55; P <.001) hospitals, as well as with radiation therapy at comprehensive cancer community (OR: 1.27; P <.001) and academic hospitals (OR: 1.23; P <.001).

CONCLUSION

Disparities in the use of WW and different primary treatments among patients with high-risk PCa persisted across different types of hospitals and over time. Our findings highlight a significant racial disparity in the use of curative therapy for high-risk PCa that should be urgently addressed to ensure that all men with PCa receive appropriate care across all racial groups and cancer care facilities.

Anesthetic Care for Orthopedic Patients

Background

Differences in health care represent a major health policy issue. Despite increasing evidence on the mediating role of anesthesia type used for surgery on perioperative outcome, there is a lack of data on potential care differences in this field. The authors aimed to determine whether anesthesia practice (use of neuraxial anesthesia [NA] or peripheral nerve block [PNB]) differs by patient and hospital factors.

Methods

The authors extracted data on n = 1,062,152 hip and knee arthroplasty procedures from the Premier Perspective database (2006 to 2013). Multilevel multivariable logistic regression models measured associations (odds ratios [ORs] and 95% CIs) between patient/hospital factors and NA or PNB use.

Results

Of all patients, 22.2% (n = 236,083) received NA and 17.9% (n = 189,732) received PNB. Lower adjusted odds for receiving NA were seen for black patients (OR, 0.88; 95% CI, 0.86 to 0.91) and those on Medicaid (OR, 0.78; 95% CI, 0.74 to 0.82) or without insurance (OR, 0.89; 95% CI, 0.81 to 0.98). Furthermore, teaching hospitals (compared with nonteaching hospitals) had lower adjusted odds for NA utilization (OR, 0.35; 95% CI, 0.14 to 0.89). Although generally similar patterns were seen for PNB utilization, the main difference was that particularly Hispanic patients were less likely to receive PNB compared with white patients (OR, 0.60; 95% CI, 0.56 to 0.65). Sensitivity analyses generally validated our results.

Conclusions

Significant differences exist in the provision of regional anesthetic care with factors such as race and insurance type being important determinants of anesthetic practice. Further and in-depth research is needed to fully assess the background of these differences.

Prostate cancer in men of African origin

Men of African origin are disproportionately affected by prostate cancer: prostate cancer incidence is highest among men of African origin in the USA, prostate cancer mortality is highest among men of African origin in the Caribbean, and tumour stage and grade at diagnosis are highest among men in sub-Saharan Africa. Socioeconomic, educational, cultural, and genetic factors, as well as variations in care delivery and treatment selection, contribute to this cancer disparity. Emerging data on single-nucleotide-polymorphism patterns, epigenetic changes, and variations in fusion-gene products among men of African origin add to the understanding of genetic differences underlying this disease. On the diagnosis of prostate cancer, when all treatment options are available, men of African origin are more likely to choose radiation therapy or to receive no definitive treatment than white men. Among men of African origin undergoing surgery, increased rates of biochemical recurrence have been identified. Understanding differences in the cancer-survivorship experience and quality-of-life outcomes among men of African origin are critical to appropriately counsel patients and improve cultural sensitivity. Efforts to curtail prostate cancer screening will likely affect men of African origin disproportionately and widen the racial disparity of disease.

A population-based analysis of contemporary patterns of care in younger men (<60 years old) with localized prostate cancer

PURPOSE

To analyze patterns of care in younger patients (<60 years old) with localized prostate cancer and to identify factors associated with selection of therapy using a large, population-based database.

METHODS

The Surveillance, Epidemiology, and End Results database was queried to identify men <60 years old diagnosed with localized prostate cancer between 2010 and 2011. Patients were determined to have undergone no active treatment, local therapy, radiation therapy (RT), or radical prostatectomy (RP). Univariate and multivariate logistic regression analyses were performed to identify factors associated with the use of definitive therapy.

RESULTS

A total of 12,732 men were included in this analysis. For the entire cohort, 12.5 % received no definitive treatment, 61.6 % RP, 22.0 % RT, and 3.3 % RP with adjuvant RT. Among men with low-, intermediate-, and high-risk prostate cancer, 17.2, 7.1, and 15.9 %, respectively, received no definitive therapy. RP was the most common choice of definitive therapy, utilized in 74.6 % of patients. Adjuvant RT after RP was utilized in 16.2 % of cases with positive margin and/or pT3/pT4 disease. African-American race, single marital status, and Medicaid/no insurance were associated with a decreased likelihood of receiving definitive treatment.

CONCLUSIONS

A significant proportion of younger men diagnosed with localized prostate cancer, particularly with low- or high-risk disease, are not receiving definitive therapy. African-American men, uninsured men, and patients with Medicaid or no medical insurance are less likely to receive definitive treatment.

Racial variation in the clinical and economic burden of skeletal-related events among elderly men with stage IV metastatic prostate cancer

Prostate cancer (PCa) outcomes vary widely among African American (AA) and non-Hispanic White (NHW) men. The authors investigated racial variation in the incidence of skeletal-related events (SREs) and SRE-related healthcare costs among AA and NHW men, a topic that has received limited attention in the literature. AA and NHW men diagnosed with metastatic PCa were identified from the linked Surveillance, Epidemiology and End Results-Medicare dataset. The sample included 6455 men with metastatic PCa, including 5420 NHW men and 1035 AA men. Approximately 16% experienced SREs during follow-up. AA men were less likely to experience SREs compared with NHW men, controlling for individual characteristics (adjusted odds ratio: 0.79; 95% CI: 0.66- 0.94). The SRE-specific costs were US$35,725 (US$22,190-US$49,260) among AA men and US$25,896 (US$21,669-US$30,123) among NHW men. Although AA men were less likely to experience SREs, there were substantial costs attributable to the treatment of SREs among AA men.

Effect of Patient Demographic Characteristics and Radiation Timing on PSA Reduction in Patients Treated With Definitive Radiation Therapy for Prostate Cancer

INTRODUCTION

The purpose of this study was to assess how demographic characteristics and temporal factors including time to treatment (TTT) and elapsed time of treatment (ETT) affect prostate-specific antigen (PSA) levels during and after radiation treatment for low- and intermediate-risk prostate cancer.

PATIENTS AND METHODS

A retrospective review of 1584 patients was conducted on patients diagnosed with prostate cancer between 2005 and 2013, from which 147 patients were found to have completed definitive external beam radiation therapy (EBRT) monotherapy. Demographic data, TTT (days between diagnosis and EBRT start date), ETT (days between EBRT start and stop date), and Gleason score were collected on these patients and analysis of variance was performed to analyze the relationship of these factors with PSA changes. PSA changes were calculated during treatment as the difference between pre- and posttreatment PSA levels and after treatment as 3-year and overall PSA velocities.

RESULTS

Patients who spoke Haitian Creole (P = .039) and those with a longer ETT (P = .029) had significantly greater PSA decline during treatment, primarily as a result of higher pretreatment PSA levels. Patients with Gleason score 4+3 disease had significantly greater 3-year (P = .033) and overall (P = .019) PSA velocities. Race and/or ethnicity, insurance type, marital status, and age were not associated with any PSA variable.

CONCLUSION

Disparities in prostate cancer are not reflected in PSA dynamics during or after radiation treatment, but are evident in PSA level at presentation. Timeliness of treatment was not found to affect true PSA change due to EBRT in low- and intermediate-risk prostate cancer patients.

Racial parity in tumor burden, treatment choice and survival outcomes in men with prostate cancer in the VA healthcare system

BACKGROUND

African-American men with prostate cancer typically have higher tumor risk at diagnosis, lower rates of surgical treatment and poorer cancer-specific survival compared with Caucasians. Receipt of care within the Veterans Affairs (VA) healthcare system may reduce barriers that influence these disparities.

METHODS

We sampled 1258 men with nonmetastatic prostate cancer diagnosed at the Greater Los Angeles and Long Beach VA Medical Centers between 1998 and 2004. We compared African Americans and Caucasians with respect to tumor characteristics using ordinal logistic regression, treatment choice across substrata of tumor risk using logistic regression, and cancer-specific and other-cause mortality using competing risks regression analysis.

RESULTS

Multivariate ordinal logistic regression revealed no significant differences in odds of higher tumor risk (odds ratio (OR) 1.22, 95% confidence interval (CI) 0.98-1.53, P=0.08), Gleason score (OR 0.90, 95% CI 0.7-1.16, P=0.4) or clinical stage (OR 1.04, 95% CI 0.79-1.38, P=0.8) for African Americans compared with Caucasians. African-American men had similar odds of aggressive treatment as did Caucasians for low-risk (OR 0.92, 95% CI 0.57-1.53, P=0.8), intermediate-risk (OR 0.75, 95% CI 0.44-1.26, P=0.3) and high-risk disease (OR 0.87, 95% CI 0.52-1.44, P=0.6). In competing risks regression analysis, African Americans had a lower but nonsignificant hazard of cancer-specific mortality compared with Caucasians (sub-hazard ratio 0.6, 95% CI 0.28-1.26, P=0.2) and nearly identical risk of other-cause mortality (sub-hazard ratio 0.98, 95% CI 0.78-1.22, P=0.8).

CONCLUSIONS

We found no significant differences in tumor burden, treatment choice or survival outcomes between African Americans and Caucasians cared for in the equal-access VA Healthcare setting.

Income inequality and treatment of African American men with high-risk prostate cancer

PURPOSE

Definitive treatment of high-risk prostate cancer with radical prostatectomy or radiation improves survival. We assessed whether racial disparities in the receipt of definitive therapy for prostate cancer vary by regional income.

PATIENTS AND METHODS

A cohort of 102,486 men (17,594 African American [AA] and 84,892 non-Hispanic white) with localized high-risk prostate cancer (prostate-specific antigen >20 ng/ml or Gleason ≥ 8 or stage ≥ cT2c) diagnosed from 2004 to 2010 was identified in the Surveillance, Epidemiology, and End Results database. Income was measured at the census-tract-level. We used multivariable logistic regression to assess patient and cancer characteristics associated with the receipt of definitive therapy for prostate cancer. Multivariable Fine and Gray competing risks analysis was used to evaluate factors associated with prostate cancer death.

RESULTS

Overall, AA men were less likely to receive definitive therapy than white men (adjusted odds ratio [AOR] = 0.51; 95% CI: 0.49-0.54; P<0.001), and there was a significant race/income interaction (Pinteraction = 0.016) such that there was a larger racial treatment disparity in the bottom income quintile (AOR = 0.49; 95% CI: 0.45-0.55; P<0.001) than in the top income quintile (AOR = 0.60; 95% CI: 0.51-0.71; P<0.001). After a median follow-up of 35 months, AA men in the bottom income quintile suffered the greatest prostate cancer mortality (adjusted hazard ratio = 1.47; 95% CI: 1.17-1.84; P = 0.001), compared with white men in the top income quintile.

CONCLUSIONS

Racial disparities in the receipt of definitive therapy for high-risk prostate cancer are greatest in low-income communities, suggesting that interventions to reduce racial disparities should target low-income populations first.