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Gul ZG, Sharbaugh DR, Ellimoottil C, Rak KJ, Yabes JG, Davies BJ, Jacobs BL. Telemedicine in urologic oncology care: Will telemedicine exacerbate disparities? Urol Oncol 2024; 42:28.e1-28.e7. [PMID: 38220521 DOI: 10.1016/j.urolonc.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/15/2023] [Accepted: 10/16/2023] [Indexed: 01/16/2024]
Abstract
INTRODUCTION Disparities in prostate, bladder, and kidney cancer outcomes are associated with access to care. Telemedicine can improve access but may be underutilized by certain patient populations. Our objective was to determine if the patient populations who suffer worse oncologic outcomes are the same as those who are less likely to use telemedicine. METHODS Using an institutional database, we identified all prostate, bladder and kidney cancer encounters from March 14, 2020 to October 31, 2021 (n = 15,623; n = 4, 14; n = 3,830). Telemedicine was used in 13%, 8%, and 12% of these encounters, respectively. We performed random effects modeling analysis to examine patient and provider characteristics associated with telemedicine use. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were reported as measures of association. RESULTS Among prostate, bladder, and kidney cancer patients, Black patients had lower odds of a telemedicine encounter (OR 0.51, 95% CI 0.37-0.69; OR 0.22, 95% CI 0.07-0.70; OR 0.46, 95% CI 0.24-0.86), and patients residing in small and isolated small rural towns areas had higher odds of a telemedicine encounter (OR 1.44, 95% CI 1.09-1.91; OR 2.12, 95% CI 1.14-3.94; OR 1.89, 95% CI 1.12-3.19). Compared to providers in practice ≤5 years, providers in practice for 6 to 15 years had significantly higher odds of a telemedicine encounter for prostate and bladder cancer patients (OR 4.10, 95% CI 1.4511.58; OR 3.42, 95% CI 1.09-10.77). CONCLUSION The lower rates of telemedicine use among Black patients could exacerbate pre-existing disparities in prostate, bladder, and kidney cancer outcomes.
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Affiliation(s)
- Zeynep G Gul
- Department of Surgery, Division of Urology, University of Washington in St. Louis, St. Louis, MO.
| | - Danielle R Sharbaugh
- Department of Urology, Division of Health Services Research, University of Pittsburgh, Pittsburgh, PA
| | - Chad Ellimoottil
- Department of Urology, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, Ann Arbor, MI
| | - Kimberly J Rak
- Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jonathan G Yabes
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Benjamin J Davies
- Department of Urology, Division of Health Services Research, University of Pittsburgh, Pittsburgh, PA
| | - Bruce L Jacobs
- Department of Urology, Division of Health Services Research, University of Pittsburgh, Pittsburgh, PA
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Deville C, Kamran SC, Morgan SC, Yamoah K, Vapiwala N. Radiation Therapy Summary of the AUA/ASTRO Guideline on Clinically Localized Prostate Cancer. Pract Radiat Oncol 2024; 14:47-56. [PMID: 38182303 DOI: 10.1016/j.prro.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 01/07/2024]
Abstract
PURPOSE Our purpose was to develop a summary of recommendations regarding the management of patients with clinically localized prostate cancer based on the American Urologic Association/ ASTRO Guideline on Clinically Localized Prostate Cancer. METHODS The American Urologic Association and ASTRO convened a multidisciplinary, expert panel to develop recommendations based on a systematic literature review using an a priori defined consensus-building methodology. The topics covered were risk assessment, staging, risk-based management, principles of management including active surveillance, surgery, radiation, and follow-up after treatment. Presented are recommendations from the guideline most pertinent to radiation oncologists with an additional statement on health equity, diversity, and inclusion related to guideline panel composition and the topic of clinically localized prostate cancer. SUMMARY Staging, risk assessment, and management options in prostate cancer have advanced over the last decade and significantly affect shared decision-making for treatment management. Current advancements and controversies discussed to guide staging, risk assessment, and treatment recommendations include the use of advanced imaging and tumor genomic profiling. An essential active surveillance strategy includes prostate-specific antigen monitoring and periodic digital rectal examination with changes triggering magnetic resonance imaging and possible biopsy thereafter and histologic progression or greater tumor volume prompting consideration of definitive local treatment. The panel recommends against routine use of adjuvant radiation therapy (RT) for patients with prostate cancer after prostatectomy with negative nodes and an undetectable prostate-specific antigen, while acknowledging that patients at highest risk of recurrence were relatively poorly represented in the 3 largest randomized trials comparing adjuvant RT to early salvage and that a role may exist for adjuvant RT in selected patients at highest risk. RT for clinically localized prostate cancer has evolved rapidly, with new trial results, therapeutic combinations, and technological advances. The recommendation of moderately hypofractionated RT has not changed, and the updated guideline incorporates a conditional recommendation for the use of ultrahypofractionated treatment. Health disparities and inequities exist in the management of clinically localized prostate cancer across the continuum of care that can influence guideline concordance.
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Affiliation(s)
- Curtiland Deville
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.
| | - Sophia C Kamran
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scott C Morgan
- Department of Radiology, Radiation Oncology and Medical Physics, University of Ottawa, Ottawa, Ontario, Canada
| | - Kosj Yamoah
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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Janopaul‐Naylor JR, Corriher TJ, Switchenko J, Hanasoge S, Esdaille A, Mahal BA, Filson CP, Patel SA. Disparities in time to prostate cancer treatment initiation before and after the Affordable Care Act. Cancer Med 2023; 12:18258-18268. [PMID: 37537835 PMCID: PMC10523962 DOI: 10.1002/cam4.6419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 06/19/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Delayed access to care may contribute to disparities in prostate cancer (PCa). The Affordable Care Act (ACA) aimed at increasing access and reducing healthcare disparities, but its impact on timely treatment initiation for PCa men is unknown. METHODS Men with intermediate- and high-risk PCa diagnosed 2010-2016 and treated with curative surgery or radiotherapy were identified in the National Cancer Database. Multivariable logistic regression modeled the effect of race and insurance type on treatment delay >180 days after diagnosis. Cochran-Armitage test measured annual trends in delays, and joinpoint regression assessed if 2014, the year the ACA became fully operationalized, was significant for inflection in crude rates of major delays. RESULTS Of 422,506 eligible men, 18,720 (4.4%) experienced >180-day delay in treatment initiation. Compared to White patients, Black (OR 1.79, 95% CI 1.72-1.87, p < 0.001) and Hispanic (OR 1.37, 95% CI 1.28-1.48, p < 0.001) patients had higher odds of delay. Compared to uninsured, those with Medicaid had no difference in odds of delay (OR 0.94, 95% CI 0.84-1.06, p = 0.31), while those with private insurance (OR 0.57, 95% CI 0.52-0.63, p < 0.001) or Medicare (OR 0.64, 95% CI 0.58-0.70, p < 0.001) had lower odds of delay. Mean time to treatment significantly increased from 2010 to 2016 across all racial/ethnic groups (trend p < 0.001); 2014 was associated with a significant inflection for increase in rates of major delays. CONCLUSIONS Non-White and Medicaid-insured men with localized PCa are at risk of treatment delays in the United States. Treatment delays have been consistently rising, particularly after implementation of the ACA.
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Affiliation(s)
- James R. Janopaul‐Naylor
- Department of Radiation OncologyWinship Cancer Institute at Emory UniversityAtlantaGeorgiaUSA
- Department of Radiation OncologyMemorial Sloan Kettering CancerNew YorkNew YorkUSA
| | - Taylor J. Corriher
- Department of Radiation OncologyWinship Cancer Institute at Emory UniversityAtlantaGeorgiaUSA
| | - Jeffrey Switchenko
- Department of Biostatistics and BioinformaticsRollins School of Public HealthAtlantaGeorgiaUSA
| | - Sheela Hanasoge
- Department of Radiation OncologyWinship Cancer Institute at Emory UniversityAtlantaGeorgiaUSA
| | - Ashanda Esdaille
- Department of UrologyEmory University School of MedicineAtlantaGeorgiaUSA
| | - Brandon A. Mahal
- Department of Radiation OncologyUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | | | - Sagar A. Patel
- Department of Radiation OncologyWinship Cancer Institute at Emory UniversityAtlantaGeorgiaUSA
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Washington C, Goldstein DA, Moore A, Gardner U, Deville C. Health Disparities in Prostate Cancer and Approaches to Advance Equitable Care. Am Soc Clin Oncol Educ Book 2022; 42:1-6. [PMID: 35671436 DOI: 10.1200/edbk_350751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The American Cancer Society estimates approximately 268,490 new cases of prostate cancer and approximately 34,500 deaths caused by prostate cancer in the United States for 2022. Globally, a total of 1,414,259 new cases of prostate cancer and 375,304 related deaths were reported in 2020. Well-documented health disparities and inequities exist along the continuum of care for prostate cancer management-from screening to diagnostic and staging work-up, surveillance, and treatment-ultimately impacting clinical outcomes. This session-based article discusses innovative patient-centered approaches to advance equitable prostate cancer care. It begins with a review of domestic health disparities in diagnostic imaging and radiotherapy for prostate cancer, and it summarizes barriers and solutions to achieving health equity, such as equity metrics and practice quality improvement projects. Next, a global perspective is provided that describes approaches to address financial and geographic barriers to prostate cancer care, including specific examples of strategies that emphasize the use of the cheapest method of care delivery while maintaining outcomes for drug delivery and radiotherapy.
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Affiliation(s)
- Cyrus Washington
- Department of Radiation Oncology, University of Miami School of Medicine, Miami, FL
| | - Daniel A Goldstein
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Assaf Moore
- Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel.,Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ulysses Gardner
- Department of Radiation Oncology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Curtiland Deville
- Department of Radiation Oncology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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Del Valle JP, Gold JS. ASO Author Reflections: Socioeconomic Disparities in Pancreas Cancer Resection and Survival in the Veterans Health Administration. Ann Surg Oncol 2022; 29:3203-3204. [PMID: 35015185 DOI: 10.1245/s10434-021-11315-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 12/23/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Jonathan Pastrana Del Valle
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jason S Gold
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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Del Valle JP, Fillmore NR, Molina G, Fairweather M, Wang J, Clancy TE, Ashley SW, Urman RD, Whang EE, Gold JS. Socioeconomic Disparities in Pancreas Cancer Resection and Survival in the Veterans Health Administration. Ann Surg Oncol 2022; 29:3194-3202. [PMID: 35006509 DOI: 10.1245/s10434-021-11250-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/06/2021] [Indexed: 12/17/2023]
Abstract
BACKGROUND Disparities based on socioeconomic factors such as race, ethnicity, marital status, and insurance status are associated with pancreatic cancer resection, but these disparities are usually not observed for survival after resection. It is unknown if there are disparities when patients undergo their treatment in a non-fee-for-service, equal-access healthcare system such as the Veterans Health Administration (VHA). METHODS Patients having T1-T3 M0 pancreatic adenocarcinoma diagnosed between 2006 and 2017 were identified from the VHA Corporate Data Warehouse. Socioeconomic, demographic, and tumor variables associated with resection and survival were assessed. RESULTS In total, 2580 patients with early-stage pancreatic cancer were identified. The resection rate was 36.5%. Surgical resection was independently associated with younger age [odds ratio (OR) 0.94, p < 0.001], White race (OR 1.35, p = 0.028), married status (OR 1.85, p = 0.001), and employment status (retired vs. unemployed, OR 1.41, p = 0.008). There were no independent associations with Hispanic ethnicity, geographic region, or Social Deprivation Index. Resection was associated with significantly improved survival (median 21 vs. 8 months, p = 0.001). Among resected patients, survival was independently associated with younger age (HR 1.019, p = 0.002), geographic region (South vs. Pacific West, HR 0.721, p = 0.005), and employment (employed vs. unemployed, HR 0.752, p = 0.029). Race, Hispanic ethnicity, marital status, and Social Deprivation Index were not independently associated with survival after resection. CONCLUSIONS Race, marital status, and employment status are independently associated with resection of pancreatic cancer in the VHA, whereas geographic region and employment status are independently associated with survival after resection. Further studies are warranted to determine the basis for these inequities.
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Affiliation(s)
- Jonathan Pastrana Del Valle
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nathanael R Fillmore
- Harvard Medical School, Boston, MA, USA
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Jamaica Plain, MA, USA
| | - George Molina
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mark Fairweather
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jiping Wang
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Thomas E Clancy
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Stanley W Ashley
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Richard D Urman
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Edward E Whang
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason S Gold
- Surgical Service, VA Boston Healthcare System, West Roxbury, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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Klebaner D, Travis Courtney P, Garraway IP, Einck J, Kumar A, Elena Martinez M, McKay R, Murphy JD, Parada H, Sandhu A, Stewart T, Yamoah K, Rose BS. Association of Health-Care System with Prostate Cancer-Specific Mortality in African American and Non-Hispanic White Men. J Natl Cancer Inst 2021; 113:1343-1351. [PMID: 33892497 DOI: 10.1093/jnci/djab062] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 02/19/2021] [Accepted: 03/30/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Disparities in prostate cancer-specific mortality (PCSM) between African American and non-Hispanic White (White) patients have been attributed to biological and systemic factors. We evaluated drivers of these disparities in the Surveillance, Epidemiology and End Results (SEER) national registry and an equal-access system, the Veterans Health Administration (VHA). METHODS We identified African American and White patients diagnosed with prostate cancer between 2004-2015 in SEER (N = 311,691) and the VHA (N = 90,749). We analyzed the association between race and metastatic disease at presentation using multivariable logistic regression adjusting for sociodemographic factors, and PCSM using sequential competing-risks regression adjusting for disease and sociodemographic factors. RESULTS The median follow-up was 5.3 years in SEER and 4.7 years in the VHA. African American men were more likely than White men to present with metastatic disease in SEER (adjusted odds ratio = 1.23, 95% confidence interval [CI] = 1.17-1.30), but not in the VHA (adjusted odds ratio = 1.07, 95% CI = 0.98-1.17). African American versus White race was associated with an increased risk of PCSM in SEER (subdistribution hazard ratio [SHR] = 1.32, 95% CI = 1.10-1.60), but not in the VHA (SHR = 1.00, 95% CI: 0.93-1.08). Adjusting for disease extent, PSA, and Gleason score eliminated the association between race and PCSM in SEER (aSHR 1.04, 95% CI 0.93-1.16). CONCLUSIONS Racial disparities in PCSM were present in a nationally representative registry, but not in an equal-access healthcare system, due to differences in advanced disease at presentation. Strategies to increase healthcare access may bridge the racial disparity in outcomes. Longer follow-up is needed to fully assess mortality outcomes.Disparities between African American and non-Hispanic White (White) patients in cancer-specific mortality have been described across numerous cancer types and healthcare systems[1-5]. The survival gap between African American and White patients with prostate cancer has been well-characterized, with two-fold higher prostate cancer-specific mortality (PCSM) rates among African American patients depending on the setting[1, 6-10]. This disparity has been attributed to differences in prostate cancer biology in African American men, in addition to systemic factors in mediating this disparity, such as differential access to healthcare, Prostate-Specific Antigen (PSA) screening, and distrust in the healthcare system[1, 11-16].The Veterans Health Administration (VHA) is a relatively equal-access healthcare system that treats a large, ethnically diverse population of veterans. The Surveillance, Epidemiology and End Results (SEER) program is a national cancer registry program that collects data from the general United States (US) population. The goals of the present investigation were to 1) Compare PCSM between African American and White men within SEER and the VHA and 2) Identify modifiable system-level contributors to these disparities. We hypothesized that PCSM would be comparable among African American and White men in an equal-access setting, the VHA, but not in a national registry, SEER, and that this disparity in SEER would be in part driven by more advanced disease at presentation.
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Affiliation(s)
- Daniella Klebaner
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California
| | - P Travis Courtney
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Isla P Garraway
- Department of Urology, University of California Los Angeles School of Medicine, Los Angeles, California
| | - John Einck
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California
| | - Abhishek Kumar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California
| | - Maria Elena Martinez
- Department of Population Sciences, University of California San Diego Moores Cancer Center, La Jolla, California.,Wertheim School of Public Health, University of California San Diego, La Jolla, California
| | - Rana McKay
- Department of Medicine, University of California San Diego School of Medicine, La Jolla, California
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Humberto Parada
- Department of Epidemiology and Biostatistics, San Diego State University Graduate School of Public Health,San Diego, California
| | - Ajay Sandhu
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California
| | - Tyler Stewart
- Department of Medicine, University of California San Diego School of Medicine, La Jolla, California
| | - Kosj Yamoah
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa Bay, Florida
| | - Brent S Rose
- Department of Radiation Medicine and Applied Sciences, University of California San Diego School of Medicine, La Jolla, California.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
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