Racial disparities in urologist visits among elderly men with prostate cancer: a cohort analysis of patient-related and county of residence-related factors

Neighborhood Disadvantage and Prostate Tumor Aggressiveness among African American and European American Men

BACKGROUND

Studies have identified associations between neighborhood disadvantage (ND), which is more likely to affect African American (AA) individuals, and aggressive prostate cancer. Thus, ND may contribute to prostate cancer disparities. However, it is unknown what ND components drive aggressive disease and whether associations vary by race.

METHODS

We evaluated associations between aggressive prostate cancer and four ND metrics-Area Deprivation Index (ADI), validated Bayesian Neighborhood Deprivation Index (NDI), racial isolation (RI) index, and historical redlining, and whether these factors interacted with race, among men with prostate cancer treated at the University of Maryland Greenebaum Comprehensive Cancer Center (2004-2021).

RESULTS

We included 1,458 men (698 European American and 760 AA). AA men were more likely to experience ND. In adjusted models, the ADI, RI, and redlining were significantly associated with aggressive versus nonaggressive prostate cancer overall [ADI, OR for one SD increase = 1.14, 95% confidence interval (CI), 1.00-1.30; RI, OR = 1.27, CI, 1.07-1.51; redlining, OR = 1.77; CI, 1.23-2.56] and among AA men. The NDI was associated with aggressive prostate cancer among AA men (OR = 1.32, 95% credible interval: 1.13-1.57); percent in poverty received the largest importance weight. The ADI (P heterogeneity = 0.002) and NDI (exceedance probability heterogeneity = 98.1%) significantly interacted with race, such that associations were significantly stronger for AA men.

CONCLUSIONS

We identified novel significant positive associations for racial segregation and historical redlining with aggressive prostate cancer and significant interactions between ND indices and race.

IMPACT

Findings inform specific ND components that are associated with aggressive prostate cancer and suggest the ND effect is stronger for AA men, which has implications for interventions to reduce disparities.

Disparity in treatment patterns among Medicare beneficiaries diagnosed with chronic lymphocytic leukemia: an analysis of patient and contextual factors

This study characterizes the patterns and timing of CLL treatment and, to our knowledge, is the first to identify social vulnerability factors associated with CLL treatment receipt in the Medicare population. A total of 3508 Medicare beneficiaries diagnosed with CLL from 2017 to 2019 were identified. We reported the proportion of individuals who received CLL treatment and the time until the first CLL treatment receipt after the first observed claim with a CLL diagnosis. Logistic regression and time-to-event models provided adjusted odds ratios and hazard ratios associated with baseline individual-level and county-level factors. Sixteen percent of individuals received CLL treatment, and the median follow-up time was 540 d. The median time to receipt of CLL treatment was 61 d. Older age and residence in a county ranked high in social vulnerability (as defined by minority status and language) were negatively associated with treatment receipt and time to treatment receipt.

Using health insurance claims data to assess long-term disease progression in a prostate cancer cohort

BACKGROUND

Long-term population-based cohort studies of men diagnosed with prostate cancer are limited. However, adverse outcomes can occur many years after treatment. Herein, we aim to assess the utility of using claims data to identify prostate cancer progression 10-15 years after diagnosis.

METHODS

The study population was derived from the North Carolina-Louisiana Prostate Cancer Project (PCaP). PCaP-North Carolina (NC) included 1031 men diagnosed with prostate cancer from 2004 to 2009. An initial follow-up with a survey and manual medical record abstraction occurred from 2008 to 2011 (Follow-up 1). Herein, we extended this follow-up with linkage to healthcare claims data from North Carolina (2011-2017) and a second, supplementary 10-year follow-up survey (2018-2020) (Follow-up 2). Vital statistics data also were utilized. Long-term oncological progression was determined using these data sources in combination with expert clinical input.

RESULTS

Among the 1031 baseline PCaP-NC participants, 652 were linked to medical claims. Forty-two percent of the men had insurance coverage for the entire 72 months of follow-up. In addition, 275 baseline participants completed the supplementary 10-year follow-up survey. Using all sources of follow-up data, we identified a progression event in 259 of 1031 (25%) men with more than 10 years of follow-up data after diagnosis.

CONCLUSIONS

Understanding long-term clinical outcomes is essential for improving the lives of prostate cancer survivors. However, access and utility of long-term clinical outcomes with claims alone remain a challenge due to individualized agreements required with each insurer for data access, lack of detailed clinical information, and gaps in insurance coverage. We were able to utilize claims data to determine long-term progression due to several unique advantages that included the availability of detailed baseline clinical characteristics and treatments, detailed manually abstracted clinical data at 5 years of follow-up, vital statistics data, and a supplementary 10-year follow-up survey.

Deconstructing, Addressing, and Eliminating Racial and Ethnic Inequities in Prostate Cancer Care

CONTEXT

Men of African ancestry have demonstrated markedly higher rates of prostate cancer mortality than men of other races and ethnicities around the world. In fact, the highest rates of prostate cancer mortality worldwide are found in the Caribbean and Sub-Saharan West Africa, and among men of African descent in the USA. Addressing this inequity in prostate cancer care and outcomes requires a focused research approach that creates durable solutions to address the structural, social, environmental, and health factors that create racial disparities in care and outcomes.

OBJECTIVE

To introduce a conceptual model for evaluating racial inequities in prostate cancer care to facilitate the development of translational research studies and interventions.

EVIDENCE ACQUISITION

A collaborative review of literature relevant to racial inequities in prostate cancer care and outcomes was performed. Existing literature was used to highlight various components of the conceptual model to inform future research and interventions toward equitable care and outcomes.

EVIDENCE SYNTHESIS

Racial inequities in prostate cancer outcomes are driven by a series of structural and social determinants of health that impact exposures, mediators, and outcomes. Social determinants of equity, such as laws/policies, economic systems, and structural racism, affect the inequitable access to environmental and neighborhood exposures, in addition to health care access. Although the incidence disparity remains problematic, various studies have demonstrated parity in outcomes when social and health factors, such as access to equitable care, are normalized. Few studies have tested interventions to reduce inequities in prostate cancer among Black men.

CONCLUSIONS

Worldwide, men of African ancestry demonstrate worse outcomes in prostate cancer, a phenomenon driven largely by social factors that inform biologic, environmental, and health care risks. A conceptual model was presented that organizes the many factors that influence prostate cancer incidence and mortality. Within that framework, we must understand the current state of inequities in clinical prostate cancer practice, the optimal state of what equitable practice would be, and how achieving equity in prostate cancer care balances costs, benefits, and harms. More robust characterization of the sources of prostate cancer inequities should inform testing of ambitious and innovative interventions as we work toward equity in care and outcomes.

PATIENT SUMMARY

Men of African ancestry demonstrate the highest rates of prostate cancer mortality, which may be reduced through social interventions. We present a framework for formalizing the identification of the drivers of prostate cancer inequities to facilitate the development of interventions and trials to eradicate them.

Why the Gap in Evaluating the Social Constructs and the Value of Medicines?

The compounding effects of occupying two or more social identities, such as being "Black" and "female" have been described in intersectionality theory. Intersectionality, a term coined by legal scholar and activist Kimberlé Crenshaw, is a framework to consider race and other social identities as overlapping, dynamic, and interdependent identities. Since its inception, intersectionality has made significant in-roads to inform the conceptualization and empirical investigations of race, gender, and other social identities in sociology, critical race theory, anthropology, feminist theory, and other disciplines. However, to date, cost effectiveness research has not systematically examined race intersecting with other social identities in the valuation of medicines using social theory, such as intersectionality. Consequently, cost effectiveness analysis, which is a method to study the value of medicines in diverse populations, has not been subject to sufficient examination through an intersectionality framework. In the US context, the racial injustices experienced and documented within diverse communities highlight that health outcomes cannot be examined in a vacuum; overlapping social identities such as race and class in relation to context have real effects on health behaviors, measured preferences, and economic costs. Failure to examine the effects of overlapping social identities on heterogeneity in benefits and costs can result in inadequate information for decision makers to evaluate the value of treatments. Without consideration of the overlapping social identities in diverse populations, there is a risk that cost effectiveness analysis results will not accurately reflect the value of treatments in socially disadvantaged populations. In this Current Opinion, we provide an outline for conducting socially conscious cost effectiveness analyses, using intersectionality as one example.

Reducing HPV Associated Cancers and Disparities: Engaging African American Men to Develop a Culturally-Appropriate Program that Addresses their Needs

Background

The Healthy Men, Health Communities program aims to improve preventive behaviors among African American men to reduce HPV-related cancer disparities.

Purpose

We describe the development of an educational intervention using cultural-targeting strategies (i.e., linguistics, peripherals, evidence, socio-culture, and constituent-involving).

Methods

After building capacity of community-based organization (CBO) leaders as research team members, we conducted 3 focus groups, 30 surveys, and a community review and program evaluation with African American men.

Results

Focus group themes were: 1) The Known and Unknown of Cancer, HPV, and the vaccine; (2) Personal experiences with cancer were commonplace; (3) Barriers to Engaging HPV Cancer Preventive Behaviors; (4) Multi-Modal Strategies are needed to improve preventive behaviors; and (5) Actual versus Preferred Sources of Information. Survey data indicated men desired information on penile (52%) and oral cancers (48%). The preferred education format was a summit with speakers on various topics (96%). Post-summit evaluation indicated majority of males intended to get screened (73%), eat healthier (77%), and exercise more (64%). About 40% reported getting themselves, children, or grandchildren the HPV vaccine.

Discussion

Our program demonstrated acceptability, feasibility, and preliminary efficacy. This work warrants further study as a potential program to improve HPV preventive behaviors among African American men.

Smoking history, intensity, and duration and risk of prostate cancer recurrence among men with prostate cancer who received definitive treatment

PURPOSE

To examine the association of smoking history and multiple measures of smoking intensity and duration with risk of biochemical recurrence in men treated for prostate cancer.

METHODS

We conducted a prospective cohort study of 1641 men (773 ever-smokers) treated with radical prostatectomy or radiation between 2003 and 2010. The association between ever-smoking and risk of biochemical recurrence was examined using Cox Proportional Hazards models with adjustment for confounders. Among ever-smokers, we further assessed the association between multiple measures of smoking duration and intensity and risk of biochemical recurrence.

RESULTS

In the full cohort, we observed no association between ever-smoking and risk of biochemical recurrence. However, among ever-smokers, a smoking duration of greater than or equal to 10 years was significantly associated with biochemical recurrence (hazard ratio: 2.32, 95% confidence interval: 1.01, 5.33). Our results also suggested that greater than or equal to 10 pack-years of smoking may be associated with an increased risk of biochemical recurrence (hazard ratio: 1.75, 95% confidence interval: 0.97, 3.15). No association was observed between packs smoked per day or years since smoking cessation (among former smokers) and risk of biochemical recurrence.

CONCLUSION

Smoking duration is a significant predicator of biochemical recurrence among men with prostate cancer who are current or former smokers.

Giving Voice to Black Men: Guidance for Increasing the Likelihood of Having a Usual Source of Care

Black men suffer inequalities in health and health-care outcomes relative to other racial/ethnic groups, requiring well-informed efforts for health promotion. Fewer Black men have a usual source of health care, which may be a contributor to these disparities. Increasing access to and the likelihood of a usual source of care among Black men are important to address health and health-care disparities. In this focus group study, we sought to better understand how Black men think about primary care and usual sources of care. A total of six focus groups were conducted with N = 25 men. Groups were a mix of men with and without a usual source of care. Several themes were identified through analysis of the data regarding factors that contribute to Black men going to the doctor. Themes identified in the data analysis included Lack of Health Insurance as a Barrier to Establishing Usual Source of Care; Family Promoting Health Care Use; Relationship With Doctor, Trust, and Empowerment; Age and Maturity in Health Promotion; and Positive Tone of Messaging. Future research should explore if similar findings are obtained among men in different regions of the United States or between Black men of different backgrounds. Taking a step beyond this research, specifically, future research can also examine the impact of particular health messages/messaging on Black men's health-care-seeking behaviors.

Predictors of Follow-Up Visits Post Radical Prostatectomy

Long-term follow-up care among prostate cancer patients is important as biochemical recurrence can occur many years after diagnosis, with 20%-30% of men experiencing biochemical recurrence within 10 years of treatment. This study examined predictors of follow-up care among 1,158 radical prostatectomy patients, treated at the Washington University in St. Louis, within 6 months, 1 year, and 2 years post surgery. Predictors examined included age at surgery, race (Black vs. White), rural/urban status, education, marital status, and prostate cancer aggressiveness. Multivariable logistic regression was used to assess the association between the predictors and follow-up visits with a urologist in 6 months, the 1st year, and the 2nd year post surgery. In a secondary analysis, any follow-up visit with a prostate-specific antigen (PSA) test was included, regardless of provider type. Men that were Black ( 6 months OR: 0.60; 95% CI [0.36, 0.99], 1 year OR: 0.34; 95% CI [0.20, 0.59], 2 year OR: 0.41; 95% CI [0.25, 0.68]), resided in a rural residence ( 1 year OR: 0.61; 95% CI [0.44, 0.85], 2 year OR: 0.41; 95% CI [0.25, 0.68]), or were unmarried ( 2 year OR: 0.69; 95% CI [0.49, 0.97]) had a reduced odds of follow-up visits with a urologist. In models where any follow-up visit with a PSA test was examined, race remained a significant predictor of follow-up. The results indicate that Black men, men residing in a rural residence, and unmarried men may not receive adequate long-term follow-up care following radical prostatectomy. These men represent a high-risk group that could benefit from increased support post treatment.

Contextual effects and cancer outcomes in the United States: a systematic review of characteristics in multilevel analyses

PURPOSE

There is increasing call for the utilization of multilevel modeling to explore the relationship between place-based contextual effects and cancer outcomes in the United States. To gain a better understanding of how contextual factors are being considered, we performed a systematic review.

METHODS

We reviewed studies published between January 1, 2002 and December 31, 2016 and assessed the following attributes: (1) contextual considerations such as geographic scale and contextual factors used; (2) methods used to quantify contextual factors; and (3) cancer type and outcomes. We searched PubMed, Scopus, and Web of Science and initially identified 1060 studies. One hundred twenty-two studies remained after exclusions.

RESULTS

Most studies utilized a two-level structure; census tracts were the most commonly used geographic scale. Socioeconomic factors, health care access, racial/ethnic factors, and rural-urban status were the most common contextual factors addressed in multilevel models. Breast and colorectal cancers were the most common cancer types, and screening and staging were the most common outcomes assessed in these studies.

CONCLUSIONS

Opportunities for future research include deriving contextual factors using more rigorous approaches, considering cross-classified structures and cross-level interactions, and using multilevel modeling to explore understudied cancers and outcomes.

Geographical Factors Associated with Health Disparities in Prostate Cancer

Background

Treatment variation in prostate cancer is common, and it is driven by clinical and clinician factors, patient preferences, availability of resources, and access to physicians and treating facilities. Most research on treatment disparities in men with prostate cancer has focused on race and socioeconomic factors. However, the geography of disparities — capturing racial and socioeconomic differences based on where patients live — can provide insight into barriers to care and help identify outlier areas in which access to care, health resources, or both are more pronounced.

Methods

Research regarding treatment patterns and disparities in prostate cancer using the Geographical Information System (GIS) was searched. Studies were limited to English-language articles and research focused on US populations. A total of 43 articles were found; of those, 30 provided information about or used spatial or geographical analyses to assess and describe differences or disparities in prostate cancer and its treatment. Two additional GIS resources were included.

Results

The research on geographical and spatial determinants of prostate cancer disparities was reviewed. We also examined geographical analyses at the state level, focusing on Florida. Overall, we described a geographical framework to disparities that affect men with prostate cancer and reviewed existing published evidence supporting the interplay of geographical factors and disparities in prostate cancer.

Conclusions

Disparities in prostate cancer are common and persistent, and notable differences in treatment are observable across racial and socioeconomic strata. Geographical analysis provides additional information about where disparate groups live and also helps to map access to care. This information can be used by public health officials, health-systems administrators, clinicians, and policymakers to better understand and respond to geographical barriers that contribute to disparities in care.

Cost Prediction Using a Survival Grouping Algorithm: An Application to Incident Prostate Cancer Cases

BACKGROUND

Prognostic classification approaches are commonly used in clinical practice to predict health outcomes. However, there has been limited focus on use of the general approach for predicting costs. We applied a grouping algorithm designed for large-scale data sets and multiple prognostic factors to investigate whether it improves cost prediction among older Medicare beneficiaries diagnosed with prostate cancer.

METHODS

We analysed the linked Surveillance, Epidemiology and End Results (SEER)-Medicare data, which included data from 2000 through 2009 for men diagnosed with incident prostate cancer between 2000 and 2007. We split the survival data into two data sets (D0 and D1) of equal size. We trained the classifier of the Grouping Algorithm for Cancer Data (GACD) on D0 and tested it on D1. The prognostic factors included cancer stage, age, race and performance status proxies. We calculated the average difference between observed D1 costs and predicted D1 costs at 5 years post-diagnosis with and without the GACD.

RESULTS

The sample included 110,843 men with prostate cancer. The median age of the sample was 74 years, and 10% were African American. The average difference (mean absolute error [MAE]) per person between the real and predicted total 5-year cost was US$41,525 (MAE US$41,790; 95% confidence interval [CI] US$41,421-42,158) with the GACD and US$43,113 (MAE US$43,639; 95% CI US$43,062-44,217) without the GACD. The 5-year cost prediction without grouping resulted in a sample overestimate of US$79,544,508.

CONCLUSION

The grouping algorithm developed for complex, large-scale data improves the prediction of 5-year costs. The prediction accuracy could be improved by utilization of a richer set of prognostic factors and refinement of categorical specifications.

African American Participation in Oncology Clinical Trials--Focus on Prostate Cancer: Implications, Barriers, and Potential Solutions

In the United States, the incidence and mortality rates of many cancers, especially prostate cancer, are disproportionately high among African American men compared with Caucasian men. Recently, mortality rates for prostate cancer have declined more rapidly in African American versus Caucasian men, but prostate cancer is still the most common cancer and the second leading cause of cancer deaths in African American men in the United States. Compared with Caucasian men, prostate cancer occurs at younger ages, has a higher stage at diagnosis, and is more likely to progress after definitive treatments in African American men. Reasons for racial discrepancies in cancer are multifactorial and potentially include socioeconomic, cultural, nutritional, and biologic elements. In addition to improving access to novel therapies, clinical trial participation is essential to adequately establish the risks and benefits of treatments in African American populations. Considering the disproportionately high mortality rates noted in these groups, our understanding of the natural history and responses to therapies is limited. This review will explore African American underrepresentation in clinical trials with a focus on prostate cancer, and potentially effective strategies to engage African American communities in prostate cancer research. Solutions targeting physicians, investigators, the community, and health care systems are identified. Improvement of African American participation in prostate cancer clinical trials will benefit all stakeholders.