Differences according to socioeconomic status in the management and mortality in men with high risk prostate cancer

Geographic and socioeconomic variation in treatment of elderly prostate cancer patients in Norway - a national register-based study

PURPOSE

The aim of this study was to examine geographic and socioeconomic variation in curative treatment and choice of treatment modality among elderly prostate cancer (PCa) patients.

METHODS

This register-based cohort study included all Norwegian men ≥ 70 years when diagnosed with non-metastatic, high-risk PCa in 2011-2020 (n = 10 807). Individual data were obtained from the Cancer Registry of Norway, the Norwegian Prostate Cancer Registry, and Statistics Norway. Multilevel logistic regression analysis was used to model variation across hospital referral areas (HRAs), incorporating clinical, demographic and socioeconomic factors.

RESULTS

Overall, 5186 (48%) patients received curative treatment (radical prostatectomy (RP) (n = 1560) or radiotherapy (n = 3626)). Geographic variation was found for both curative treatment (odds ratio 0.39-2.19) and choice of treatment modality (odds ratio 0.10-2.45). Odds of curative treatment increased with increasing income and education, and decreased for patients living alone, and with increasing age and frailty. Patients with higher income had higher odds of receiving RP compared to radiotherapy.

CONCLUSIONS

This study showed geographic and socioeconomic variation in treatment of elderly patients with non-metastatic, high-risk PCa, both in relation to overall curative treatment and choice of treatment modality. Further research is needed to explore clinical practices, the shared decision process and how socioeconomic factors influence the treatment of elderly patients with high-risk PCa.

Trends in prostate cancer mortality in the United States of America, by state and race, from 1999 to 2019: estimates from the centers for disease control WONDER database

BACKGROUND

In the United States of America (USA), prostate cancer (PC) is the most common cancer in men and the second cause of cancer mortality. Black men (BM) have a higher incidence and worse mortality when compared to white men (WM). We compared trends in PC mortality in the USA by race and state from 1999 to 2019.

METHODS

We extracted PC mortality data from the Centers for Disease Control (CDC) WONDER database using the International Classification of Diseases (ICD) 10 code C61. Age-Standardized Mortality Rates (ASMR) were divided into racial groups and reported by year and state. Due to the lack of available data in many states, analyses were conducted only for WM and BM using Joinpoint regression for trend comparisons.

RESULTS

Between 1999-2019, ASMR decreased at the national level in Black (-44.6%), Asian (-44.8%), White (-31.8%), and American Indian or Alaskan native men (-19.0%). ASMR decreased in all states for both races. The greatest drop in ASMR was in Kentucky (-47.0%) for WM and Delaware (-57.8%) for BM. In 2019, ASMRs in BM (13.4/100 000) were significantly higher than WM (7.3/100 000), American Indian or Alaskan Native (3.2/100 000), and Asian men (3.2/100 000) (p < 0.001). The highest ASMRs were in Nebraska (33.5/100 000) for BM and Alaska (11/100 000) for WM.

CONCLUSIONS

During the last 20 years, the PC mortality rate dropped in all states for all races, suggesting an advancement in management strategies. Although a higher decrease in ASMR was observed in BM, ASMR remain higher among BM. ASMRs were also found to be increasing in many states post USPSTF guideline change (2012), indicating a need for more education around optimized prostate cancer screening.

Medicare accountable care organizations: post-acute care use and post-surgical outcomes in urologic cancer surgery

OBJECTIVES

To evaluate association between Medicare accountable care organizations (ACOs) participation of hospitals on post-acute care (PAC) use and spending, and post-surgical outcomes in Medicare beneficiaries undergoing urologic cancer surgeries. Despite increasing prevalence of urologic cancer and surgical care contributing to a large proportion of total health care costs, and recent Medicare payment reforms such as accountable care organizations, the role of ACOs in urologic cancer care has been unexplored.

METHODS

We conducted a longitudinal analysis of 2011-2017 Medicare claims data to compare post-surgical outcomes between Medicare ACO and non-ACO patients before and after implementation of Medicare shared savings program (MSSP). Our outcomes of interest were Post-acute care (PAC) use (overall, institutional, and home health), Skilled Nursing Facility (SNF) length of stay and Medicare spending for SNF patients, 30-day and 90-day unplanned readmissions and complications after index procedure.

RESULTS

Study sample included a total of 334,514 Medicare patients undergoing bladder, prostate, kidney cancer surgeries at 524 Medicare ACO and 2066 non-ACO hospitals. For bladder cancer surgery, Medicare ACO participation was associated with significantly reduced overall post-acute care use, but not with changes in readmission or complication rate. For prostate cancer and kidney cancer surgery, we found no significant association between hospital participation in Medicare ACOs and PAC use or post-surgical outcomes.

CONCLUSIONS

Hospital participation in MSSP ACOs leads to lower post-acute care use without compromising patient outcomes for Medicare beneficiaries undergoing bladder cancer surgery. Future research is needed to understand longer-term impact of ACO participation on urologic cancer surgery outcomes.

Direct mail from primary care and targeted recruitment strategies achieved a representative uptake of prostate cancer screening

OBJECTIVES

Prostate cancer screening studies has previously not been able to reflect a diverse group of participants. We evaluated a range of recruitment strategies and their ability to recruit from the Black population and areas of deprivation.

STUDY DESIGN AND SETTINGS

IP1-PROSTAGRAM was a prospective, population-based, paired screening study of 408 participants conducted at seven UK primary care practices and two imaging centres. All participants underwent screening with a PSA test, MRI and transrectal ultrasound. A number of recruitment strategies were embedded including direct mail, media campaigns and a targeted recruitment strategy to increase participation among harder-to-reach groups.

RESULTS

1,316 expressions of interest in total were received (20^th September 2018 to 15th May 2019). The direct mail strategy generated 317 expressions of interest from 1707 invitation letters. 387 expressions of interest were received following the targeted strategy and 612 from media campaigns. The recruitment target was met 19 months ahead of schedule. Of 411 participants, ethnicity was White (38.0%), Black (32.4%), Asian (23.0%) and Other/Mixed (4.4%) ethnic groups. This higher recruitment of black men was driven by the targeted recruitment strategy. A comparison of recruitment methods showed marked differences between ethnicities recruited (p<0.001). The proportion of black participants recruited by direct mail (8%) was similar to the prevalence of black local population (9%) whereas targeted recruitment was 88% (115) and media recruitment 1.7% (1). The Index of Multiple Deprivation (IMD) distribution was similar to the local population with marginal higher recruitment from more deprived areas; proportion increasing from 26% to 40% from least to most deprived IMD quintiles (Quintiles 4/5 vs. 1/2). Direct mail recruited a close-to-normal distribution for deprivation with targeted recruitment trending towards recruiting from most deprived areas.

CONCLUSIONS

Direct mail and targeted strategies designed to engage a diverse population can achieve a representative uptake from black participants and those from a lower socioeconomic group.

Smoking and Risk of Prostate Cancer and Prostate Cancer Death: A Pooled Study

BACKGROUND

Prospective and detailed investigations of smoking and prostate cancer (PCa) risk and death are lacking.

OBJECTIVE

To investigate prediagnosis smoking habit (status, intensity, duration, and cessation) as a risk factor, on its own and combined with body mass index (BMI), for PCa incidence and death.

DESIGN, SETTING, AND PARTICIPANTS

We included 351448 men with smoking information from five Swedish cohorts.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We used Cox regression to calculate hazard ratios (HRs) and confidence intervals (CIs) for PCa incidence (n = 24731) and death (n = 4322).

RESULTS AND LIMITATIONS

Smoking was associated with a lower risk of any PCa (HR 0.89, 95% CI 0.86-0.92), which was most pronounced for low-risk PCa (HR 0.74, 95% CI 0.69-0.79) and was restricted to PCa cases diagnosed in the prostate-specific antigen (PSA) era. Smoking was associated with a higher risk of PCa death in the full cohort (HR 1.10, 95% CI 1.02-1.18) and in case-only analysis adjusted for clinical characteristics (HR 1.20, 95% CI 1.11-1.31), which was a consistent finding across case groups (p = 0.8 for heterogeneity). Associations by smoking intensity and, to lesser degree, smoking duration and cessation, supported the associations for smoking status. Smoking in combination with obesity (BMI ≥30 kg/m²) further decreased the risk of low-risk PCa incidence (HR 0.40, 95% CI 0.30-0.53 compared to never smokers with BMI <25 kg/m²) and further increased the risk of PCa death (HR 1.49, 95% CI 1.21-1.84). A limitation of the study is that only a subgroup of men had information on smoking habit around the time of their PCa diagnosis.

CONCLUSIONS

The lower PCa risk for smokers in the PSA era, particularly for low-risk PCa, can probably be attributed to low uptake of PSA testing by smokers. Poor survival for smokers, particularly obese smokers, requires further study to clarify the underlying causes and the preventive potential of smoking intervention for PCa death.

PATIENT SUMMARY

Smokers have a higher risk of dying from prostate cancer, which further increases with obesity.

Relationship between socioeconomic status and prostate cancer (incidence, aggressiveness, treatment with curative intent, and mortality): a spatial analysis using population-based cancer registry data

BACKGROUND

Morbidity and mortality associated with prostate cancer in a given geographic area might be related to the level of socioeconomic deprivation. The Somme area (a region of northern France) is considered economically disadvantaged, with major territorial disparities. The aim of this study was to assess the impact of the socioeconomic level on prostate cancer, using data from a population-based cancer registry.

METHODS

The source of data on cases of prostate cancer between 2006 and 2010 was the Somme cancer registry (Amiens, France). Socioeconomic status was measured according to the European Deprivation Index (EDI), which was used to classify each geographical "IRIS" unit (the smallest sub-municipal geographical entity for which French census data are available) according to its level of social deprivation. For spatial analysis, we considered a hierarchical generalized linear model.

RESULTS

In the spatial analysis, prostate cancer incidence was higher in the less disadvantaged areas and treatment frequency with curative intent was lower in the most disadvantaged areas. Cancer aggressiveness and mortality were higher in the most disadvantaged areas: relative risk (RR) = 1.36; 95% CI: [1.09; 1.73] and RR=3.09 [1.70; 5.59], respectively.

CONCLUSION

Our results evidenced a significant association between socioeconomic deprivation and prostate cancer, with worse outcomes among men with the lowest socioeconomic status.

Men and sexual and reproductive healthcare in the Nordic countries: a scoping review

CONTEXT

Men generally seek healthcare less often than women and, other than traditional gender norms, less is known about the explanation. The aim was to identify knowledge gaps and factors influencing men regarding sexual and reproductive healthcare (SRHC) in the Nordic countries.

METHODS

We searched PubMed and SveMed+ for peer-reviewed articles published between January 2010 and May 2020. The analyses identified factors influencing men's experiences of and access to SRHC.

RESULTS

The majority of the 68 articles included focused on pregnancy, birth, infertility and sexually transmitted infections including HIV. During pregnancy and childbirth, men were treated as accompanying partners rather than individuals with their own needs. The knowledge and attitudes of healthcare providers were crucial for their ability to provide SRHC and for the experiences of men. Organisational obstacles, such as women-centred SRHC and no assigned healthcare profession for men's sexual and reproductive health issues, hindered men's access to SRHC. Lastly, the literature rarely discussed the impact of health policies on men's access to SRHC.

CONCLUSIONS

The literature lacked the perspectives of specific groups of men such as migrants, men who have sex with men and transmen, as well as the experiences of men in SRHC related to sexual function, contraceptive use and gender-based violence. These knowledge gaps, taken together with the lack of a clear entry point for men into SRHC, indicate the necessity of an improved health and medical education of healthcare providers, as well as of health system interventions.

PSA testing patterns in a large Swedish cohort before the implementation of organized PSA testing

BACKGROUND

Organized PSA testing for asymptomatic men aged 50-74 years will be implemented in Sweden to reduce opportunistic testing in groups who will not benefit. The aim of this study was to describe the opportunistic PSA testing patterns in a Swedish region before the implementation of organized PSA testing programs.

METHOD

We included all men in the Uppsala-Örebro health care region of Sweden who were PSA tested between 1 July 2012 and 30 June 2014. Information regarding previous PSA testing, prostate cancer diagnosis, socioeconomic situation, surgical procedures and prescribed medications were collected from population-wide registries to create the Uppsala-Örebro PSA cohort (UPSAC). The cohort was divided into repeat and single PSA testers. The background population used for comparison consisted of men 40 years or older, living in the Uppsala-Örebro region during this time period.

RESULTS

Of the adult male population in the region, 18.1% had undergone PSA testing. Among men over 85 years old 21% where PSA tested. In our cohort, 62.1% were repeat PSA testers. Of men with a PSA level ≤1µg/l 53.8% had undergone repeat testing. Prostate cancer was found in 2.7% and 4.8% of the repeat and single testers, respectively.

CONCLUSION

Every fifth man in the male background population was PSA tested. Repeated PSA testing was common despite low PSA values. As repeated PSA testing was common, especially among older men who will not be included in organized testing, special measures to change the testing patterns in this group may be required.

Patients' education level and treatment modality for prostate cancer in the Finnish Randomized Study of Screening for Prostate Cancer

BACKGROUND

In prostate cancer (PCa), lower education level is associated with less screening, more advanced stage at diagnosis and worse survival. The aim of this study was to estimate the association between education level and treatment modality and subsequently survival.

METHODS

The 9255 men diagnosed with PCa in the Finnish Randomized Study of Screening for Prostate Cancer were included. Cancer stage, comorbidity, education level and primary treatment modality were extracted from the patient records, the Finnish Cancer Registry, Statistics Finland and the National Institute of Health and Welfare, and these covariates were used in logistic regression (treatment selection) and Cox regression (survival analysis).

RESULTS

In high-risk cancers, men with tertiary education were more likely to be treated with radical prostatectomy (odds ratio [OR] = 1.76; 95% confidence interval [CI] = 1.27-2.44) than men with primary education. Men with secondary (OR = 0.57; 95% CI = 0.38-0.84) or tertiary (OR = 0.42; 95% CI = 0.29-0.60) education were managed less frequently with mere hormonal therapy. In locally advanced cases, tertiary education was associated with more curatively aimed therapies and less hormonal therapy (OR for radical prostatectomy = 2.34; 95% CI = 1.49-3.66; OR for radiotherapy = 1.42; 95% CI = 1.09-1.85; OR for hormonal therapy = 0.45; 95% CI = 0.33-0.60). The hazard ratio for PCa death was lower in men with secondary (0.81; 95% CI = 0.69-0.95) and tertiary (0.75; 95% CI = 0.65-0.87) education than in the patients with primary education.

CONCLUSIONS

When controlled for the cancer risk group, comorbidity and patient's age, low education level is independently associated with less curatively aimed treatment in men with high-risk or locally advanced PCa and subsequently worse prognosis.

Socioeconomic disparity trends in diagnostic imaging, treatments, and survival for non-small cell lung cancer 2007-2016

Socioeconomic status (SES) has led to treatment and survival disparities; however, limited data exist for non‐small cell lung cancer (NSCLC). This study investigates the impact of SES on NSCLC diagnostic imaging, treatment, and overall survival (OS), and describes temporal disparity trends. The Ontario Cancer Registry was used to identify NSCLC patients diagnosed between 2007 and 2016. Through linkage to administrative datasets, patients’ demographics, imaging, treatment, and survival were obtained. Based on median household neighborhood income, the Ontario population was divided into five income quintiles (Q1‐Q5; Q1 = lowest income). Multivariable regressions assessed SES association with OS, imaging, treatment receipt, and treatment delay, and their interaction with year of diagnosis to understand temporal trends. Endpoints were adjusted for demographics, stage and comorbidities, along with treatments and imaging for OS. A total of 50 542 patients were identified. Higher SES patients (Q5 vs. Q1) showed improved 5‐year OS (hazard ratio, 0.89; 95% confidence interval [CI], 0.87‐0.92; P < .0001) and underwent greater magnetic resonance imaging head (stages IA‐IV; odds ratio [OR], 1.24; 95% CI, 1.16‐1.32; P < .0001), lung resection (IA‐IIIA; OR, 1.58; 95% CI, 1.43‐1.74; P < .0001), platinum‐based vinorelbine adjuvant chemotherapy (IB‐IIIA; OR, 1.63; 95% CI, 1.39‐1.92; P < .0001), palliative radiation (IV; OR, 1.14; 95% CI, 1.05‐1.25; P = .023), and intravenous chemotherapy (IV; OR, 1.45; 95% CI, 1.32‐1.60; P < .0001). Lower SES patients underwent greater thoracic radiation (IA‐IIIB; OR, 0.86; 95% CI, 0.79‐0.94; P = .0003). Across 2007‐2016, socioeconomic disparities remain largely unchanged (interaction P > .05) despite widening income inequality.

ECCO Essential Requirements for Quality Cancer Care: Prostate cancer

BACKGROUND

ECCO Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give oncology teams, patients, policymakers and managers an overview of essential care throughout the patient journey.

PROSTATE CANCER

Prostate cancer is the second most common male cancer and has a wide variation in outcomes in Europe. It has complex diagnosis and treatment challenges, and is a major healthcare burden. Care must only be a carried out in prostate/urology cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

Emerging cancer incidence, mortality, hospitalisation and associated burden among Australian cancer patients, 1982 - 2014: an incidence-based approach in terms of trends, determinants and inequality

OBJECTIVE

Cancer is a leading killer worldwide, including Australia. Cancer diagnosis leads to a substantial burden on the individual, their family and society. The main aim of this study is to understand the trends, determinants and inequalities associated with cancer incidence, hospitalisation, mortality and its burden over the period 1982 to 2014 in Australia.

SETTINGS

The study was conducted in Australia.

STUDY DESIGN

An incidence-based study design was used.

METHODS

Data came from the publicly accessible Australian Institute of Health and Welfare database. This contained 2 784 148 registered cancer cases over the study period for all types of cancer. Erreygers' concentration index was used to examine the magnitude of socioeconomic inequality with regards to cancer outcomes. Furthermore, a generalised linear model was constructed to identify the influential factors on the overall burden of cancer.

RESULTS

The results showed that cancer incidence (annual average percentage change, AAPC=1.33%), hospitalisation (AAPC=1.27%), cancer-related mortality (AAPC=0.76%) and burden of cancer (AAPC=0.84%) all increased significantly over the period. The same-day (AAPC=1.35%) and overnight (AAPC=1.19%) hospitalisation rates also showed an increasing trend. Further, the ratio (least-most advantaged economic resources ratio, LMR of mortality (M) and LMR of incidence (I)) was especially high for cervix (M/I=1.802), prostate (M/I=1.514), melanoma (M/I=1.325), non-Hodgkin's lymphoma (M/I=1.325) and breast (M/I=1.318), suggesting that survival inequality was most pronounced for these cancers. Socioeconomically disadvantaged people were more likely to bear an increasing cancer burden in terms of incidence, mortality and death.

CONCLUSIONS

Significant differences in the burden of cancer persist across socioeconomic strata in Australia. Policymakers should therefore introduce appropriate cancer policies to provide universal cancer care, which could reduce this burden by ensuring curable and preventive cancer care services are made available to all people.

Educational level and first-time PSA testing in general practice

Introduction: Different patterns in the use of prostate-specific antigen (PSA) testing might explain socioeconomic differences in prostate cancer incidence and mortality. We examined the association between socioeconomic position, measured as education and first-time PSA testing in general practice.Material and Methods: A population-based cohort study of men aged 45-79 years without prior prostate cancer diagnosis living in the Capital Region of Denmark between 2000 and 2014. Information on socioeconomic indicators (education, income, cohabitation status and work market affiliation), prostate cancer diagnoses, and vital status were obtained from national registries. Date of first PSA test was obtained from the Copenhagen Primary Care Laboratory database. Temporal trends of PSA testing were calculated as annual age-standardised incidence rates and the association was examined by a multivariable Cox proportional hazards model.Results: The cohort consists of 431,997 men of which 105,476 (24%) had a first-time PSA test in the study period. Men with longer education, higher income, living with a partner, and employed had higher rates of PSA testing. For men with short education, the rate of PSA test was 28.3 tests per 1000 person-years compared to 31.2 tests among men with long education. The fully adjusted hazard ratio for a first PSA test among men with short education was 0.87 (95% CI, 0.85-0.89) compared to men with long education.Conclusion: The association between education and first-time PSA testing indicates socioeconomic disparities in health care utilisation, which could explain part of the observed socioeconomic difference in prostate cancer incidence and mortality.

Comparative effectiveness of treatments for high-risk prostate cancer patients

BACKGROUND

To determine the comparative effectiveness of primary radical prostatectomy (RP) compared to external bean radiation therapy (EBRT) with androgen deprivation therapy (ADT), or EBRT plus brachytherapy (BT) with or without ADT among Medicare fee-for-service beneficiaries with high-risk prostate cancer, for 10-year, mortality (overall and prostate cancer-specific), complications, health service use, and cost.

METHODS

This population-based cohort study used Surveillance, Epidemiology, and End Results - Medicare data. Eligible patients were men aged 66 or older and diagnosed with high-risk prostate cancer between 1996 and 2003. Outcomes evaluated were 10-year overall mortality and prostate cancer-specific mortality, complications, health service use, and cost. We used Cox regression, Poisson regression, and Generalized Linear Model (GLM) log-link models to assess the outcomes.

MAIN FINDINGS

The 10-year overall mortality of EBRT + ADT was comparable to that of the RP group (hazard ratio [HR] = 1.09, confidence interval [CI] = 0.72-1.66). The EBRT + BT ± ADT group had overall survival advantage compared to RP (HR = 0.47, CI = 0.31-0.73). Compared to the RP group, EBRT + ADT group had higher 10-year prostate cancer-specific mortality (HR = 2.19, CI = 1.92-5.21). Both EBRT + ADT and EBRT + BT ± ADT were associated with higher 10-year cost (odds ratio = 1.72, CI = 1.35-2.20; and odds ratio = 1.63, CI = 1.29-2.04), compared to RP group. Complications and health service use varied across 3 treatment groups and across phases of care.

PRINCIPAL CONCLUSIONS

Our results also demonstrate long-term overall survival benefits for EBRT + BT ± ADT, and greater bowel and bladder side effects over a decade, compared to RP. The RP group had advantage for long-term prostate-cancer specific mortality, compared to EBRT + ADT group. Thus, RP can provide superior cancer control with clear cost advantage for older men with high-risk disease. In terms of value proposition, our results support RP as preferred treatment option, compared to EBRT + ADT and EBRT + BT ± ADT for high-risk prostate cancer patients.

The association between education and risk of major cardiovascular events among prostate cancer patients: a study from the Diet, Cancer and Health study

Background: High socioeconomic position is associated with better prognosis in prostate cancer patients but it is unknown if part of this association may be explained by socioeconomic differences in severe late effects. We investigated the association between education as an indicator for socioeconomic position and cardiovascular events after prostate cancer and if such associations were mediated by differences in lifestyle, cardiovascular risk factors and prostate cancer treatment. Material and methods: We identified 1980 men diagnosed with prostate cancer from 1993 to 2014 among participants in the Danish Diet, Cancer and Health study. Individual level information on education, lifestyle, cardiovascular risk factors and prostate cancer clinical information were obtained from questionnaires, registries and medical records. The Cox proportional hazards models were used to evaluate the risk of incident acute myocardial infarction, ischemic stroke and heart failure during up to 18 years of follow-up for men with short (<9 years) or medium (9-12 years) compared with long education (>12 years). Results: Compared to men with long education, we found an increased risk of acute myocardial infarction in men with medium and short education (HR 3.14, 95% CI 1.53-6.47 and HR 2.14, 95% CI 0.82-5.58, respectively). Adjusting for stage, first-line treatment, lifestyle and cardiovascular risk factors did not change the HRs substantially (adjusted HRs 3.04, 95% CI 1.47-6.31 and 2.07, 95% CI 0.78-5.53, respectively). There were no educational differences in risk for ischemic stroke or heart failure. Conclusions: The risk of acute myocardial infarction was increased in prostate cancer patients with short or medium education compared with long education. Although the educational inequality did not seem to be explained by differences in treatment, lifestyle or cardiovascular risk factors, monitoring of cardiovascular health and health promotion should involve all prostate cancer patients regardless of social position to ensure best prognosis for all.

Sociodemographic factors and choice of oral anticoagulant in patients with non-valvular atrial fibrillation in Sweden: a population-based cross-sectional study using data from national registers

Background

The Swedish healthcare system aims to provide equal access to care to all residents yet evidence suggests that patients with low socioeconomic status are less likely to receive new drugs. Associations between sociodemographics and prescription of non-vitamin K antagonist oral anticoagulants (NOACs) as an alternative to warfarin in Sweden have not been investigated.

Methods

We conducted a cross-sectional study using linked national registers in Sweden. The study population included oral anticoagulant naïve patients aged ≥18 years with non-valvular atrial fibrillation (NVAF) who filled a first prescription for a NOAC or warfarin from 01 December 2011 to 31 December 2014. Multivariable logistic regression was used to identify factors associated with the choice of anticoagulant treatment; adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated.

Results

Among 68,056 patients with NVAF, 27.4% (N = 18,638) started treatment with a NOAC and 72.6% (N = 49,418) started on warfarin. Patients starting treatment with a NOAC were more likely to be highly educated (OR 1.37, 95% CI: 1.30–1.45), in the highest income quartile (OR 1.23, 95% CI: 1.16–1.31) and have a leading professional occupation (OR 1.41, 95% CI: 1.27–1.58). Patients residing in rural areas were half as likely to start treatment with a NOAC as those in urban areas (OR 0.48, 95% CI: 0.45–0.51).

Conclusion

Among Swedish patients with NVAF, those with high socioeconomic status and urban residence were more likely to start preventative treatment with a NOAC than warfarin. Future research should explore reasons for these inequalities in NOAC treatment.

Electronic supplementary material

The online version of this article (10.1186/s12872-019-1029-z) contains supplementary material, which is available to authorized users.

Androgen deprivation therapy for prostate cancer and risk of dementia

Objectives

To study whether androgen deprivation therapy (ADT), the mainstay treatment for advanced and disseminated prostate cancer, is associated with risk of dementia.

Methods

Risk of dementia in men with prostate cancer primarily managed with ADT or watchful waiting (WW) in the Prostate Cancer Database Sweden, PCBaSe, was compared with that in prostate cancer‐free men, matched on birth year and county of residency. We used Cox regression to calculate the hazard ratios (HRs) for Alzheimer's and non‐Alzheimer's dementia (vascular dementia, dementia secondary to other diseases or unspecified dementias) for different types and duration of ADT and oral antiandrogens (AAs) as well as for men managed with WW.

Results

A total of 25 967 men with prostate cancer and 121 018 prostate cancer‐free men were followed for a median of 4 years. In both groups 6% of the men were diagnosed with dementia. In men with prostate cancer, gonadotropin‐releasing hormone agonist treatment ( HR 1.15, 95% confidence interval [CI] 1.07–1.23) and orchiectomy (HR 1.60, 95% CI 1.32–1.93) were associated with an increased risk of dementia, as compared to no treatment in prostate cancer‐free men; however, this increase in risk was only observed for non‐Alzheimer's dementia and occurred from year 1–4 after start of ADT. No increase in risk for any type of dementia was observed for men treated with AAs or for men on WW.

Conclusion

This population‐based cohort study does not support previous observations of an increased risk of Alzheimer's dementia for men on ADT; however, there was a small increase in risk of non‐Alzheimer's dementia.

Patient Characteristics at Prostate Cancer Diagnosis in Different Races at an Academic Center Serving a Diverse Population

BACKGROUND

In the United States, the prostate cancer (PCa) incidence and death rate has been greater in non-Hispanic black (NHB) men than in non-Hispanic white (NHW) men and slightly lower in Hispanic men than in NHW men. We compared the sociodemographic and baseline prognostic factors at the diagnosis of PCa in different races/ethnicities at a large, academic center serving an ethnically diverse population.

METHODS

The Montefiore Medical Center Cancer Registry was used to generate a comprehensive list of all patients with PCa diagnosed from 2004 to 2014. The clinical Looking Glass (a proprietary searchable database of patient information) and individual patient medical record review were used to obtain data, including age at diagnosis, socioeconomic status (SES), clinical Gleason score, clinical stage, and prostate-specific antigen level at diagnosis. The patients were classified by self-identified race/ethnicity as Hispanic, NHB, NHW, or other. The χ² test was used for categorical variables, and analysis of variance or the Kruskal-Wallis test was used for continuous variables.

RESULTS

We identified 2352 patients with newly diagnosed PCa during the study period, including 778 Hispanic, 1046 NHB, 486 NHW, and 42 other. The NHW men were significantly older at diagnosis (Hispanic, 63.2 years; NHB, 63.4 years; NHW, 67 years; other, 63.0 years; P < .0001). The mean SES for the Hispanic and NHB men was significantly lower (SES below average: Hispanic, 92.8%; NHB, 91.3%; NHW, 56.6%; other, 75%; P < .0001). The Gleason score at diagnosis differed among these race groups (Gleason score ≤6 PCa: Hispanic, 42.8%; NHB, 39.1%; NHW, 52.2%; other, 50%; Gleason score 8-10: Hispanic, 15.8%; NHB, 17.6%; NHW, 14.3%; other, 16.7%; P = .0005). The proportion of men with metastatic disease at diagnosis also differed significantly among the groups (Hispanic, 7.5%; NHB, 9.0%; NHW, 4.3%; other, 9.5%; P = .0139). Using pairwise comparisons, the odds ratio for a higher Gleason score at presentation between NHB and NHW was 1.592 (P < .001) and was 1.378 for Hispanic versus NHW (P = .0200). The pairwise comparison for metastatic disease at diagnosis showed an odds ratio of 2.186 for NHB versus NHW (P = .0087). After adjusting for SES, the odds ratio for a higher Gleason score comparing NHB and NHW was 1.55 (P = .001). Although the odds of metastatic disease were greater in Hispanic men than in NHW men (odds ratio, 1.784), the differences were not statistically significant (P = .1197).

CONCLUSIONS

At our center, the clinical features of men from different racial groups differed significantly at the time of newly diagnosed PCa. Differences included age at diagnosis, SES, Gleason score, and proportion with metastatic disease. Our pairwise comparisons between different ethnic groups suggested that PCa in Hispanic men might be more similar to that in NHB than to that in NHW patients and are generally more aggressive at diagnosis.

Association between post-diagnostic use of cholera vaccine and risk of death in prostate cancer patients

Recent evidence suggests that cholera toxin might have multiple functions regarding the ability to regulate the immune system. However, it is unknown whether subsequent administration of cholera vaccine might affect the mortality rate in patients with prostate cancer. Here we report that patients in Sweden, who were diagnosed with prostate cancer between July 2005 and December 2014 and used cholera vaccine, have a decreased risk of death from prostate cancer (HR, 0.57; 95% CI, 0.40-0.82) as compared to patients with prostate cancer but without cholera vaccine use, adjusted for a range of confounding factors. In addition, patients using cholera vaccine show a decreased risk of death overall (HR, 0.53; 95% CI, 0.41-0.69). The decreased mortality rate is largely consistent, irrespective of patients' age or tumor stage at diagnosis. In this population-based study, we suggest that subsequent administration of cholera vaccine after prostate cancer diagnosis might reduce the mortality rate.

Socioeconomic status and diagnosis, treatment, and mortality in men with prostate cancer. Nationwide population-based study

Patients with high socioeconomic status (SES) have better cancer outcomes than patients with low SES. This has also been shown in Sweden, a country with tax-financed health care aiming to provide care on equal terms to all residents. The association between income and educational level and diagnostics and treatment as outlined in national guidelines and prostate cancer (Pca) and all-cause mortality was assessed in 74,643 men by use of data in the National Prostate Cancer Register of Sweden and a number of other health care registers and demographic databases. In multivariable logistic regression analysis, men with high income had higher probability of Pca detected in a health-check-up, top versus bottom income quartile, odds ratio (OR) 1.60 (95% CI 1.45-1.77) and lower probability of waiting more than 3 months for prostatectomy, OR 0.77 (0.69-0.86). Men with the highest incomes also had higher probability of curative treatment for intermediate and high-risk cancer, OR 1.77 (1.61-1.95) and lower risk of positive margins, (incomplete resection) at prostatectomy, OR 0.80 (0.71-0.90). Similar, but weaker associations were observed for educational level. At 6 years of follow-up, Pca mortality was modestly lower for men with high income, which was statistically significant for localized high-risk and metastatic Pca in men with no comorbidities. All-cause mortality was less than half in top versus bottom quartile of income (12% vs. 30%, p < 0.001) among men above age 65. Our findings underscore the importance of adherence to guidelines to ensure optimal and equal care for all patients diagnosed with cancer.

The impact of socioeconomic status on stage specific prostate cancer survival and mortality before and after introduction of PSA test in Finland

Socioeconomic status (SES) has an impact on prostate cancer (PCa) outcomes. Men with high SES have higher incidence and lower mortality of PCa versus lower SES males. PCa cases diagnosed in Finland in 1985-2014 (N = 95,076) were identified from the Finnish Cancer Registry. Information on education level (EL) was obtained from Statistics Finland. EL was assessed with three-tiered scale: basic, upper secondary and higher education. PCa stage at diagnosis was defined as localized, metastatic or unknown. Years of diagnosis 1985-1994 were defined as pre-PSA period and thereafter as post-PSA period. We report PCa-specific survival (PCSS) and relative risks (RR) for PCa specific mortality (PCSM) among cancer cases in Finland, where healthcare is 100% publicly reimbursed and inequality in healthcare services low. Men with higher EL had markedly better 10-year PCSS: 68 versus 63% in 1985-1994 and 90 versus 85% in 1995-2004 compared to basic EL in localized PCa. The RR for PCSM among men with localized PCa and higher EL compared to basic EL was 0.76(95%confidence interval (CI) 0.66-0.88) in 1985-1994 and 0.61(95%CI 0.53-0.70) in 1995-2004. Variation in PCSS and PCSM between EL categories was evident in metastatic PCa, too. The difference in PCSM between EL categories was larger in the first 10-year post-PSA period than before that but decreased thereafter in localized PCa, suggesting PSA testing became earlier popular among men with high EL. In summary, higher SES/EL benefit PCa survival both in local and disseminated disease and the effect of EL was more pronounced in early post-PSA period.

Eighteen-year follow-up of the Göteborg Randomized Population-based Prostate Cancer Screening Trial: effect of sociodemographic variables on participation, prostate cancer incidence and mortality

OBJECTIVE

This study examined whether previously reported results, indicating that prostate-specific antigen (PSA) screening can reduce prostate cancer (PC) mortality regardless of sociodemographic inequality, could be corroborated in an 18 year follow-up.

MATERIALS AND METHODS

In 1994, 20,000 men aged 50-64 years were randomized from the Göteborg population register to PSA screening or control (1:1) (study ID: ISRCTN54449243). Men in the screening group (n = 9950) were invited for biennial PSA testing up to the median age of 69 years. Prostate biopsy was recommended for men with PSA ≥2.5 ng/ml. Last follow-up was on 31 December 2012.

RESULTS

In the screening group, 77% (7647/9950) attended at least once. After 18 years, 1396 men in the screening group and 962 controls had been diagnosed with PC [hazard ratio 1.51, 95% confidence interval (CI) 1.39-1.64]. Cumulative PC mortality was 0.98% (95% CI 0.78-1.22%) in the screening group versus 1.50% (95% CI 1.26-1.79%) in controls, an absolute reduction of 0.52% (95% CI 0.17-0.87%). The rate ratio (RR) for PC death was 0.65 (95% CI 0.49-0.87). To prevent one death from PC, the number needed to invite was 231 and the number needed to diagnose was 10. Systematic PSA screening demonstrated greater benefit in PC mortality for men who started screening at age 55-59 years (RR 0.47, 95% CI 0.29-0.78) and men with low education (RR 0.49, 95% CI 0.31-0.78).

CONCLUSIONS

These data corroborate previous findings that systematic PSA screening reduces PC mortality and suggest that systematic screening may reduce sociodemographic inequality in PC mortality.

Association of Human Development Index with global bladder, kidney, prostate and testis cancer incidence and mortality

OBJECTIVES

To describe contemporary worldwide age-standardized incidence and mortality rates for bladder, kidney, prostate and testis cancer and their association with development.

MATERIALS AND METHODS

We obtained gender-specific, age-standardized incidence and mortality rates for 184 countries and 16 major world regions from the GLOBOCAN 2012 database. We compared the mortality-to-incidence ratios (MIRs) at national and regional levels in males and females, and assessed the association with socio-economic development using the 2014 United Nations Human Development Index (HDI).

RESULTS

Age-standardized incidence rates were 2.9 (bladder) to 7.4 (testis) times higher for genitourinary malignancies in more developed countries compared with less developed countries. Age-standardized mortality rates were 1.5-2.2 times higher in more vs less developed countries for prostate, bladder and kidney cancer, with no variation in mortality rates observed in testis cancer. There was a strong inverse relationship between HDI and MIR in testis (regression coefficient 1.65, R² = 0.78), prostate (regression coefficient -1.56, R² = 0.85), kidney (regression coefficient -1.34, R² = 0.74), and bladder cancer (regression coefficient -1.01, R² = 0.80).

CONCLUSION

While incidence and mortality rates for genitourinary cancers vary widely throughout the world, the MIR is highest in less developed countries for all four major genitourinary malignancies. Further research is needed to understand whether differences in comorbidities, exposures, time to diagnosis, access to healthcare, diagnostic techniques or treatment options explain the observed inequalities in genitourinary cancer outcomes.

Socioeconomic position and mortality among patients with prostate cancer: influence of mediating factors

INTRODUCTION

Men with low socioeconomic position experience higher mortality after a prostate cancer diagnosis compared to men with a higher socioeconomic position, however, the specific mediators of this association are unclear. We therefore evaluated the influence of potential mediators on the association between socioeconomic position, and prostate cancer-specific and all-cause death in prostate cancer patients.

MATERIALS AND METHODS

We conducted a cohort study of prostate cancer patients in the Danish Diet, Cancer and Health study. All patients completed questionnaires and anthropometric measurements at enrollment. Information on educational level, income, comorbidity and vital status was obtained by linkage to Danish nationwide registries. Clinical data and anthropometric measures were collected from medical records at diagnosis. Cox proportional hazard models were used to compute hazard ratios (HR) for all-cause and prostate cancer-specific death according to socioeconomic position and potential mediators.

RESULTS

We included 953 prostate cancer patients identified among 27 179 male participants in the Diet, Cancer and Health study who were followed for a median of 6.5 years (interquartile range 6.4-11.2 years). Patients with low socioeconomic position were more often overweight or obese at baseline. Low socioeconomic position was associated with increased prostate cancer-specific and all-cause death. The increased mortality could largely be explained by tumor aggressiveness, comorbidity, treatment and metabolic indicators, except for patients in the lowest income group.

DISCUSSION

Our study confirmed the a priori assumption that socioeconomic position is associated with increased mortality after prostate cancer. The increased mortality could largely be explained by lifestyle and clinical parameters.

Causes of death in men with localized prostate cancer: a nationwide, population-based study

OBJECTIVE

To detail the distribution of causes of death from localized prostate cancer (PCa).

PATIENTS AND METHODS

The database PCBase Sweden links the Swedish National Prostate Cancer Register with other nationwide population-based healthcare registers. We selected all 57 187 men diagnosed with localized PCa between 1997 and 2009 and their 114 374 PCa-free control subjects, matched according to age and county of residence. Mortality was calculated using competing risk regression analyses, taking into account PCa risk category, age and Charlson comorbidity index (CCI).

RESULTS

In men with low-risk PCa, all-cause mortality was lower compared with that in corresponding PCa-free men: 10-year all-cause mortality was 18% for men diagnosed at age 70 years, with a CCI score of 0, and 21% among corresponding control subjects. Of these cases, 31% died from cardiovascular disease (CVD) compared with 37% of the corresponding control subjects. For men with low-risk PCa, 10-year PCa-mortality was 0.4, 1 and 3% when diagnosed at age 50, 60 and 70 years, respectively. PCa was the third most common cause of death (18%), after CVD (31%) and other cancers (30%). By contrast, PCa was the most common cause of death in men with intermediate- and high-risk localized PCa.

CONCLUSIONS

Men with low-risk PCa had lower all-cause mortality than PCa-free men because of lower CVD mortality, driven by early detection selection; however, for men with intermediate- or high-risk disease, the rate of PCa death was substantial, irrespective of CCI score, and this was even more pronounced for those diagnosed at age 50 or 60 years.

A population-based study on the association between educational length, prostate-specific antigen testing and use of prostate biopsies

OBJECTIVE

The aim of this study was to determine whether educational length affects prostate-specific antigen (PSA) testing and the time to prostate biopsy for men with raised PSA values.

MATERIALS AND METHODS

Using register data on all men in Stockholm County in 2013 (n = 1,052,841), the limited-duration point prevalence of PSA testing and time between test and prostate biopsy or repeat testing were analysed. Patterns of follow-up were assessed using Kaplan-Meier product limit estimators and Cox proportional hazard models. Educational length was categorized as short (≤ 9 years), intermediate (10-12 years) or long (≥ 13 years).

RESULTS

PSA testing increased with educational length in all age groups. Among men aged 50-69 years, 61% with long and 54% with short education had had a PSA test within the preceding 10 years (p < 0.001). In men with PSA 4-10 ng/ml, 40% [95% confidence interval (CI) 38-41] with long and 27% (95% CI 26-29) with short education underwent a prostate biopsy within 12 months. After adjusting for PSA level and age, educational length was still associated with the chance of having a prostate biopsy in men with PSA 4-10 ng/ml (hazard ratio 1.22, 95% CI 1.12-1.31), but not in men with higher PSA values.

CONCLUSION

PSA testing increased with educational length. Men with long education were more likely to have a prostate biopsy after an increased PSA value below 10 ng/ml than men with short education. These differences may contribute to the worse prostate cancer outcomes observed among men with lower socioeconomic status.

Socioeconomic inequalities in prostate cancer survival: A review of the evidence and explanatory factors

Although survival rates after prostate cancer diagnosis have improved in the past two decades, survival analyses regarding the socioeconomic status (SES) suggest inequalities indicating worse prognosis for lower SES groups. An overview of the current literature is lacking and moreover, there is an ongoing discussion about the underlying causes but evidence is comparatively sparse. Several patient, disease and health care related factors are discussed to have an important impact on disparities in survival. Therefore, a systematic review was conducted to sum up the current evidence of survival inequalities and the contribution of different potential explanatory factors among prostate cancer patients. The PubMed database was screened for relevant articles published between January 2005 and September 2014 revealing 330 potentially eligible publications. After systematic review process, 46 papers met the inclusion criteria and were included in the review. About 75% of the studies indicate a significant association between low SES and worse survival among prostate cancer patients in the fully adjusted model. Overall, hazard ratios (low versus high SES) range from 1.02 to 3.57. A decrease of inequalities over the years was not identified. 8 studies examined the impact of explanatory factors on the association between SES and survival by progressive adjustment indicating mediating effects of comorbidity, stage at diagnosis and treatment modalities. Eventually, an apparent majority of the obtained studies indicates lower survival among patients with lower SES. The few studies that intend to explain inequalities found out instructive results regarding different contributing factors but evidence is still insufficient.

Unemployment and prostate cancer mortality in the OECD, 1990-2009

The global economic downturn has been associated with increased unemployment in many countries. Insights into the impact of unemployment on specific health conditions remain limited. We determined the association between unemployment and prostate cancer mortality in members of the Organisation for Economic Co-operation and Development (OECD). We used multivariate regression analysis to assess the association between changes in unemployment and prostate cancer mortality in OECD member states between 1990 and 2009. Country-specific differences in healthcare infrastructure, population structure, and population size were controlled for and lag analyses conducted. Several robustness checks were also performed. Time trend analyses were used to predict the number of excess deaths from prostate cancer following the 2008 global recession. Between 1990 and 2009, a 1% rise in unemployment was associated with an increase in prostate cancer mortality. Lag analysis showed a continued increase in mortality years after unemployment rises. The association between unemployment and prostate cancer mortality remained significant in robustness checks with 46 controls. Eight of the 21 OECD countries for which a time trend analysis was conducted, exhibited an estimated excess of prostate cancer deaths in at least one of 2008, 2009, or 2010, based on 2000-2007 trends. Rises in unemployment are associated with significant increases in prostate cancer mortality. Initiatives that bolster employment may help to minimise prostate cancer mortality during times of economic hardship.

Health disparities and cancer: racial disparities in cancer mortality in the United States, 2000-2010

Declining cancer incidence and mortality rates in the United States (U.S.) have continued through the first decade of the twenty-first century. Reductions in tobacco use, greater uptake of prevention measures, adoption of early detection methods, and improved treatments have resulted in improved outcomes for both men and women. However, Black Americans continue to have the higher cancer mortality rates and shorter survival times. This review discusses and compares the cancer mortality rates and mortality trends for Blacks and Whites. The complex relationship between socioeconomic status and race and its contribution to racial cancer disparities is discussed. Based on current trends and the potential and limitations of the patient protection and affordable care act with its mandate to reduce health care inequities, future trends, and challenges in cancer mortality disparities in the U.S. are explored.

Serum prostate-specific antigen levels and type of work in tire manufacturing workers

Objectives

This study measures serum prostate-specific antigen (PSA) levels in tire-manufacturing workers, and attempts to find occupational or non-occupational factors that related to their PSA levels.

Methods

A total of 1,958 healthy male workers (1,699 were production workers and 259 were office workers) took PSA measurement for analysis.

Results

After adjusting for age, body mass index, hypertension, regular exercise, alcohol drinking and smoking, which were significantly related to serum PSA levels or known related factors of serum PSA levels, the geometric mean PSA levels were significantly high in the office workers (p = 0.017), the older age group (p < 0.001), the group with hypertension (p = 0.046) and the group of individuals that do not exercise regularly (p = 0.015) and the office workers were more likely to have a serum PSA level of ≥4.0 (OR 7.73, 95% CI: 2.78-21.46) or 2.5 ng/mL (OR 2.74, 95% CI: 1.49-5.08). After stratifying by age and adjusting aforementioned covariates, office workers 50 years of age and older had the significantly higher geometric mean PSA levels (p = 0.017) and were more likely to have a serum PSA level of ≥4.0 ng/mL (OR 12.90, 95% CI: 3.65-45.64) or 2.5 ng/mL (OR 3.90, 95% CI: 1.64-9.25) than production workers 50 years of age and older.

Conclusions

This study showed that serum PSA levels were significantly higher among the group with hypertension or the group of individuals that did not exercise regularly or group of office workers who were considered to have lesser physical activities.

Research in cancer care disparities in countries with universal healthcare: mapping the field and its conceptual contours

The paper reviews published studies focused on disparities in receipt of cancer treatments and supportive care services in countries where cancer care is free at the point of access. We map these studies in terms of the equity stratifiers they examined, the countries in which they took place, and the care settings and cancer populations they investigated. Based on this map, we reflect on patterns of scholarly attention to equity and disparity in cancer care. We then consider conceptual challenges and opportunities in the field, including how treatment disparities are defined, how equity stratifiers are defined and conceptualized and how disparities are explained, with special attention to the challenge of psychosocial explanations.

Multilevel Factors Associated With Overall Mortality for Men Diagnosed With Prostate Cancer in Florida

To identify individual and contextual factors contributing to overall mortality among men diagnosed with prostate cancer in Florida, a random sample of patients (between October 1, 2001, and December 31, 2007) was taken from the Florida Cancer Data System. Patient's demographic and clinical information were obtained from the Florida Cancer Data System. Comorbidity was computed following the Elixhauser Index method. Census-tract-level socioeconomic status and farm house presence were extracted from Census 2000 and linked to patient data. The ratio of urologists and radiation oncologists to prostate cancer cases at the county level was computed. Multilevel logistic regression was conducted to identify significance of individuals and contextual factors in relation to overall mortality. A total of 18,042 patients were identified, among whom 2,363 died. No racial difference was found in our study. Being older at diagnosis, unmarried, current smoker, uninsured, diagnosed at late stage, with undifferentiated, poorly differentiated, or unknown tumor grade were significantly associated with higher odds of overall mortality. Living in a low-income area was significantly associated with higher odds of mortality (p = .0404). After adjusting for age, stage, and tumor grade, patients who received hormonal, combination of radiation with hormone therapy, and no definitive treatment had higher odds of mortality compared with those who underwent surgery only. A large number of comorbidities were associated with higher odds of mortality. Although disease-specific mortality was not examined, our findings suggest the importance of careful considerations of patient sociodemographic characteristics and their coexisting conditions in treatment decision making, which in turn affects mortality.

Population-based study on use of chemotherapy in men with castration resistant prostate cancer

BACKGROUND

Chemotherapy prolongs life and relieves symptoms in men with castration resistant prostate cancer (CRPC). There is limited information on a population level on the use of chemotherapy for CRPC.

MATERIAL AND METHODS

To assess the use of chemotherapy in men with CRPC we conducted a register-based nationwide population-based study in Prostate Cancer data Base Sweden (PCBaSe) and a nationwide in-patient drug register (SALT database) between May 2009 and December 2010. We assumed that men who died of prostate cancer (PCa) underwent a period of CRPC before they died.

RESULTS

Among the 2677 men who died from PCa during the study inclusion period, 556 (21%) had received chemotherapy (intravenous or per oral) detectable within the observation period in SALT database. Specifically, 239 (61%) of men < 70 years had received chemotherapy, 246 (30%) of men between 70 and 79 years and 71 (5%) men older than 80 years. The majority of men 465/556 (84%) had received a docetaxel-containing regimen. Among chemotherapy treated men, 283/556 (51%) received their last dose of chemotherapy during the last six months prior to death. Treatment with chemotherapy was more common among men with little comorbidity and high educational level, as well as in men who had received curatively intended primary treatment.

CONCLUSION

A majority of men younger than 70 years with CRPC were treated with chemotherapy in contrast to men between 70 and 79 years of whom half as many received chemotherapy. Chemotherapy treatment was often administered shortly prior to death. The low uptake of chemotherapy in older men with CRPC may be caused by concerns about tolerability of treatment, as well as treatment decisions based on chronological age rather than global health status.

Clinical trial participation and outcome for patients with glioblastoma: multivariate analysis from a comprehensive dataset

Glioblastoma multiforme (GBM) is the most common malignant brain tumor in adults. Although multiple clinical and tumor-related variables affect survival outcomes, the effect of clinical trial participation has not been explored. The aim of this study was to determine whether clinical trial participation improves outcome for patients with GBM. Data from patients with GBM were accessed from a dataset collected over 12 years (1998-2010) at two institutions. Univariable and multivariate logistic regression analyses were performed to look for relationships between clinical trial participation, other baseline clinical and sociodemographic variables and overall survival (OS). In total, 542 patients were identified and included in the analysis; median age was 62 years. Sixty-one patients (11%) were enrolled in a clinical trial. Clinical trial enrollment was associated with improved median survival (14.5 months compared to 6.3 months, p < 0.001) and this difference remained significant in multivariate analysis (hazard ratio 0.67, p = 0.046). Age, poor performance status and operation type were also independent predictors for OS in multivariate analysis. Disease site, socioeconomic status and co-morbidity did not affect survival outcome. This is the first study in patients with GBM to suggest a survival benefit from clinical trial participation, independent of age and performance status; while also confirming the importance of other previously reported prognostic factors. This should encourage clinicians to offer trial therapies to patients with GBM and encourage patients to participate in available studies.

Bridging the gap between biologic, individual, and macroenvironmental factors in cancer: a multilevel approach

To address the complex nature of cancer occurrence and outcomes, approaches have been developed to simultaneously assess the role of two or more etiologic agents within hierarchical levels including the: (i) macroenvironment level (e.g., health care policy, neighborhood, or family structure); (ii) individual level (e.g., behaviors, carcinogenic exposures, socioeconomic factors, and psychologic responses); and (iii) biologic level (e.g., cellular biomarkers and inherited susceptibility variants). Prior multilevel approaches tend to focus on social and environmental hypotheses, and are thus limited in their ability to integrate biologic factors into a multilevel framework. This limited integration may be related to the limited translation of research findings into the clinic. We propose a "Multi-level Biologic and Social Integrative Construct" (MBASIC) to integrate macroenvironment and individual factors with biology. The goal of this framework is to help researchers identify relationships among factors that may be involved in the multifactorial, complex nature of cancer etiology, to aid in appropriate study design, to guide the development of statistical or mechanistic models to study these relationships, and to position the results of these studies for improved intervention, translation, and implementation. MBASIC allows researchers from diverse fields to develop hypotheses of interest under a common conceptual framework, to guide transdisciplinary collaborations, and to optimize the value of multilevel studies for clinical and public health activities.

Does a surgeon's annual radical prostatectomy volume predict the risk of positive surgical margins and urinary incontinence at one-year follow-up? Findings from a prospective national study

OBJECTIVE

This study aimed to assess the prevalence of positive surgical margins (PSM) and urinary incontinence (UI) in relation to surgeons' annual radical prostatectomy (RP) volume.

MATERIAL AND METHODS

This national study prospectively assessed 521 preoperatively continent patients with prostate cancer (PCa), scheduled for RP by surgeons with high (>50), medium (20-50) or low annual volume (<20) at 14 urological departments in Norway. Patients responded to UI questions from the Expanded Composite prostate cancer index (EPIC-50) before and 1 year after RP. UI was defined as "use of pad(s)" and/or "a moderate or severe urinary leakage problem (ULP)". Preoperative prediction of PSMs and UI was explored in multivariate regression analyses with the following independent variables: surgeons' annual RP volume, type of hospital (university versus community), patient's health, sociodemographic features and PCa characteristics.

RESULTS

Based on histopathological reports, the overall PSM rate was 26%, with differences between the high- (18%), medium- (28%) and low-volume (44%) groups. Increasing PSM rates were predicted by surgeons belonging to the low- and medium-volume categories, prostate-specific antigen> 10 µg/l, Gleason score >7, patient age >65 years and <12 years of education. At 1-year follow-up 40% reported UI, without significant differences between the volume groups. Only 46% of those who used pad(s) experienced ULP. UI was predicted by clinical category ≥T2 and community type of hospital, but not by surgeons' annual RP volume. CONCLUSIONS. Preoperative counselling should take into account the relationship between surgeon's annual RP volume and PSM rate and the current knowledge about UI and ULP.