Variation in prostate cancer treatment associated with population density of the county of residence

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.

Identification and classification of principal features for analyzing unwarranted clinical variation

RATIONALE, AIMS, AND OBJECTIVE

Unwarranted clinical variation (UCV) is an undesirable aspect of a healthcare system, but analyzing for UCV can be difficult and time-consuming. No analytic feature guidelines currently exist to aid researchers. We performed a systematic review of UCV literature to identify and classify the features researchers have identified as necessary for the analysis of UCV.

METHODS

The literature search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We looked for articles with the terms 'medical practice variation' and 'unwarranted clinical variation' from four databases: Medline, Web of Science, EMBASE and CINAHL. The search was performed on 24 March 2023. The articles selected were original research articles in the English language reporting on UCV analysis in adult populations. Most of the studies were retrospective cohort analyses. We excluded studies reporting geographic variation based on the Atlas of Variation or small-area analysis methods. We used ASReview Lab software to assist in identifying articles for abstract review. We also conducted subsequent reference searches of the primary articles to retrieve additional articles.

RESULTS

The search yielded 499 articles, and we reviewed 46. We identified 28 principal analytic features utilized to analyze for unwarranted variation, categorised under patient-related or local healthcare context factors. Within the patient-related factors, we identified three subcategories: patient sociodemographics, clinical characteristics, and preferences, and classified 17 features into seven subcategories. In the local context category, 11 features are classified under two subcategories. Examples are provided on the usage of each feature for analysis.

CONCLUSION

Twenty-eight analytic features have been identified, and a categorisation has been established showing the relationships between features. Identifying and classifying features provides guidelines for known confounders during analysis and reduces the steps required when performing UCV analysis; there is no longer a need for a UCV researcher to engage in time-consuming feature engineering activities.

Impact of Social Determinants of Health on Stereotactic Radiotherapy for Vestibular Schwannoma

OBJECTIVES/HYPOTHESIS

Linear accelerator (LINAC) and Gamma Knife (GK) are common stereotactic radiation therapies for treating vestibular schwannoma (VS). There is currently limited literature examining specific demographic and socioeconomic factors, which influence the type of stereotactic radiation therapy a patient with VS receives.

STUDY DESIGN

Retrospective database review.

METHODS

The National Cancer Database was queried for cases of VS between 2004 and 2016. Patient demographic characteristics were compared using chi-squared and t-tests between GK and LINAC treated groups. Multivariate regression analysis was performed to assess predictors of stereotactic radiation therapy received.

RESULTS

Of the 6,208 included patients, 5,306 (85.5%) received GK and 902 (14.5%) received LINAC. The mean age of GK patients was significantly lower than that of LINAC patients (58.0 vs. 59.7, P < .001). Individuals treated with GK had greater proportions of private insurance (P < .001) and incomes greater than $63,332 (P = .003). A greater proportion of GK patients were treated in academic centers (P < .001), in high-volume facilities (P < .001), in metropolitan areas (P < .001), and in the Northeastern United States (P < .001). On multivariate logistic regression analysis, region, metropolitan area, facility type, tumor size, and distance traveled by patients independently predict receipt of GK versus LINAC.

CONCLUSION

Differences in patient demographics and other social determinants of health influence choice of GK versus LINAC therapy for VS patients. Future studies focused on addressing barriers to care, which may influence postprocedural quality of life and clinical outcomes associated with these two treatments are necessary to better understand the impact of these social differences.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Regional Variation in Active Surveillance for Low-Risk Prostate Cancer in the US

Importance

Active surveillance (AS) is now recognized as the preferred management option for most low-risk prostate cancers to minimize risks of overtreatment. Despite increasing use of AS in the US, wide regional variability has been observed, and these regional variations in contemporary practice have not been well described.

Objective

To explore variations between county and Surveillance, Epidemiology, and End Results (SEER) regions in AS in the US.

Design, Setting, and Participants

A cohort study using the SEER Prostate with Watchful Waiting (WW) database linked to the County Area Health Resource File for detailed county-level demographics and physician distribution data was conducted from January 2010 to December 2015. Analysis was performed in October 2020. A total of 79 825 men with clinically localized, low-risk prostate cancer eligible for AS or WW were included.

Exposures

Multiple patient-, county-, and SEER region-level factors, including age, year of diagnosis, county-level densities of urologists, radiation oncologists, primary care physicians, and SEER registry region.

Main Outcomes and Measures

Use of AS or WW as the initial reported treatment strategy were noted. Hierarchical mixed-effect logistic regression models were used to evaluate clustered random regional variation on use of AS or WW. Temporal trends by year in proportions of initial treatment type, as well as county-level local variation, were also estimated.

Results

Of 79 825 men (mean [SD] age, 62.8 [7.6] years, 11 292 [14.1%] non-Hispanic Black, 7506 [9.4%] Hispanic) with low-risk prostate cancer, the mean annualized percent increase in AS rates from 2010 to 2015 ranged from 6.3% in New Mexico to 81.0% in New Jersey. Differences across SEER regions accounted for 17% of the total variation in AS. Increasing age (51-60 years: odds ratio [OR], 1.33; 95% CI, 1.21-1.46; 61-70 years: OR, 1.86; 95% CI, 1.70-2.04; 71-80 years: OR, 2.26; 95% CI, 2.05-2.50) was associated with greater odds of AS. Hispanic ethnicity (OR, 0.79; 95% CI, 0.74-0.85), T category (OR, 0.79; 95% CI, 0.73-0.84), and Medicaid enrollment (OR, 0.73; 95% CI, 0.66-0.81) were associated with lower odds of AS. Black race, county-level socioeconomic factors (household income, educational level, and city type), and specialist densities were not associated with AS use.

Conclusions and Relevance

In this US cohort study based on the SEER-WW database, although the use of AS increased, considerable practice variation appeared to be associated with geographic location, but use of AS was not associated with Black race, specialty professional density, or socioeconomic factors. This small area variation underlies the broader national trends in AS practice and may inform policies aimed at continuing to affect risk-appropriate care for men throughout the US.

Rural-urban differences in health-related quality of life: patterns for cancer survivors compared to other older adults

PURPOSE

Health-related quality of life (HRQOL) among older cancer survivors can be impaired by factors such as treatment, comorbidities, and social challenges. These HRQOL impairments may be especially pronounced in rural areas, where older adults have higher cancer burden and more comorbidities and risk factors for poor health. This study aimed to assess rural-urban differences in HRQOL for older cancer survivors and controls.

METHODS

Data came from Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS), which links cancer incidence from 18 U.S. population-based cancer registries to survey data for Medicare Advantage Organization enrollees (1998-2014). HRQOL measures were 8 standardized subscales and 2 global summary measures. We matched (2:1) controls to breast, colorectal, lung, and prostate cancer survivors, creating an analytic dataset of 271,640 participants (ages 65+). HRQOL measures were analyzed with linear regression models including multiplicative interaction terms (rurality by cancer status), controlling for sociodemographics, cohort, and multimorbidities.

RESULTS

HRQOL scores were higher in urban than rural areas (e.g., global physical component summary score for breast cancer survivors: urban mean = 38.7, standard error [SE] = 0.08; rural mean = 37.9, SE = 0.32; p < 0.05), and were generally lower among cancer survivors compared to controls. Rural cancer survivors had particularly poor vitality (colorectal: p = 0.05), social functioning (lung: p = 0.05), role limitation-physical (prostate: p < 0.01), role limitation-emotional (prostate: p < 0.01), and global mental component summary (prostate: p = 0.02).

CONCLUSION

Supportive interventions are needed to increase physical, social, and emotional HRQOL among older cancer survivors in rural areas. These interventions could target cancer-related stigma (particularly for lung and prostate cancers) and/or access to screening, treatment, and ancillary healthcare resources.

Prostate Cancer Incidence and Aggressiveness in Appalachia versus Non-Appalachia Populations in Pennsylvania by Urban-Rural Regions, 2004-2014

BACKGROUND

Few studies have examined prostate cancer incidence and aggressiveness in urban-rural Appalachian populations. We examined these rates in urban-rural Appalachia and non-Appalachia Pennsylvania (PA), and the association between these areas and more aggressive prostate cancer at diagnosis.

METHODS

Men, ages ≥ 40 years with a primary prostate cancer diagnosis, were identified from the 2004-2014 Pennsylvania Cancer Registry. Age-adjusted incidence rates for prostate cancer and more aggressive prostate cancer at diagnosis were calculated by urban-rural Appalachia status. Multivariable Poisson regressions were conducted. Multiple logistic regressions were used to examine the association between the geographic areas and more aggressive prostate cancer, after adjusting for confounders.

RESULTS

There were 94,274 cases, ages 40-105 years, included. Urban non-Appalachia had the highest 2004-2014 age-adjusted incidence rates of prostate cancer and more aggressive prostate cancer (293.56 and 96.39 per 100,000 men, respectively) and rural Appalachia had the lowest rates (256.48 and 80.18 per 100,000 men, respectively). Among the cases, urban Appalachia were more likely [OR = 1.12; 95% confidence interval (CI) = 1.08-1.17] and rural Appalachia were less likely (OR = 0.92; 95% CI = 0.87-0.97) to have more aggressive prostate cancer at diagnosis compared with urban non-Appalachia.

CONCLUSIONS

Lower incidence rates and the proportion of aggressive disease in rural Appalachia may be due to lower prostate cancer screening rates. More aggressive prostate cancer at diagnosis among the cases in urban Appalachia may be due to exposures that are prevalent in the region.

IMPACT

Identifying geographic prostate cancer disparities will provide information to design programs aimed at reducing risk and closing the disparity gap.

Combining Drive Time and Urologist Density to Understand Access to Urologic Care

OBJECTIVE

To improve our understanding of timely access to urologic care, we leveraged driving time combined with a measure of urologist density.

MATERIALS AND METHODS

We identified all urologists who billed Medicare using National Provider Identifier in 2015 and geocoded their practice location. We developed drive-time based service areas for each provider using Esri's street network dataset stratified into 30, 60, 90, and 120-minute areas. Population characteristics were aggregated and block groups were assigned to a Hospital Referral Region.

RESULTS

We identified 10,170 urologists that billed Medicare in 2015 in the United States. Compared to the northeast, vast expanses of land across the western United States have drive times to urology care >60 minutes. However, less than 13% of the US population is unable to obtain urologic care within 30 minutes. Likely reflecting rural populations, White and American Indian populations are represented in greater proportion among those requiring a longer drive time to urologic care. Disparities were noted between areas with timely access to a high versus low density of urologists; low density areas have a greater proportion of Black and Asian populations and greater income inequality.

CONCLUSIONS

Drive time to urologists combined with urologist density is a novel approach to investigating urologic care access and a tool for health disparities research. While almost all of the US population lives within 1-hour drive time to a urologist there remains important differences in the population severed by high compared to low provider density.

The association between neighborhood greenness and incidence of lethal prostate cancer: A prospective cohort study

Supplemental Digital Content is available in the text.

Growing evidence suggests that neighborhood contextual environment could influence risk factors and, therefore, incidence of lethal prostate cancer. We studied the association between neighborhood greenness and lethal prostate cancer incidence and assessed mediation by vigorous physical activity.

Geographical Variations in Prostate Cancer Outcomes: A Systematic Review of International Evidence

Background: Previous reviews of geographical disparities in the prostate cancer continuum from diagnosis to mortality have identified a consistent pattern of poorer outcomes with increasing residential disadvantage and for rural residents. However, there are no contemporary, systematic reviews summarizing the latest available evidence. Our objective was to systematically review the published international evidence for geographical variations in prostate cancer indicators by residential rurality and disadvantage.

Methods: Systematic searches of peer-reviewed articles in English published from 1/1/1998 to 30/06/2018 using PubMed, EMBASE, CINAHL, and Informit databases. Inclusion criteria were: population was adult prostate cancer patients; outcome measure was PSA testing, prostate cancer incidence, stage at diagnosis, access to and use of services, survival, and prostate cancer mortality with quantitative results by residential rurality and/or disadvantage. Studies were critically appraised using a modified Newcastle-Ottawa Scale.

Results: Overall 169 studies met the inclusion criteria. Around 50% were assessed as high quality and 50% moderate. Men from disadvantaged areas had consistently lower prostate-specific antigen (PSA) testing and prostate cancer incidence, poorer survival, more advanced disease and a trend toward higher mortality. Although less consistent, predominant patterns by rurality were lower PSA testing, prostate cancer incidence and survival, but higher stage disease and mortality among rural men. Both geographical measures were associated with variations in access and use of prostate cancer-related services for low to high risk disease.

Conclusions: This review found substantial evidence that prostate cancer indicators varied by residential location across diverse populations and geographies. While wide variations in study design limited comparisons across studies, our review indicated that internationally, men living in disadvantaged areas, and to a lesser extent more rural areas, face a greater prostate cancer burden. This review highlights the need for a better understanding of the complex social, environmental, and behavioral reasons for these variations, recognizing that, while important, geographical access is not the only issue. Implementing research strategies to help identify these processes and to better understand the central role of disadvantage to variations in health outcome are crucial to inform the development of evidence-based targeted interventions.

Comparative effectiveness in urology: a state of the art review utilizing a systematic approach

PURPOSE OF REVIEW

Comparative effectiveness research plays a vital role in healthcare delivery by guiding evidence-based practices. We performed a state-of-the-art review of comparative effectiveness research in the urology literature for 2016, utilizing a systematic approach. Seven high-impact papers are reviewed in detail.

RECENT FINDINGS

Across the breadth of urology, there were several important studies in comparative effectiveness research, of which we will highlight two randomized controlled trials and five observational trials: radiotherapy, prostatectomy, and active monitoring have equivalent mortality outcomes in patients with localized prostate cancer; the ideal modality of patient education is yet to be determined, and written education has minimal effect on patient perception of prostate specific antigen screening; robotic prostatectomy is associated with higher perioperative complication rates on a population basis; racial disparities exist in incontinence rates after treatment for localized prostate cancer, but not in irritative, bowel, or sexual function; androgen deprivation therapy is associated with higher fracture, peripheral artery disease, and cardiac-related complications than bilateral orchiectomy; robotic and open cystectomy offer comparable cancer-specific mortality and perioperative outcomes; and bonuses for low-cost hospitals can inadvertently reward low-quality hospitals.

SUMMARY

There have been major advancements in comparative effectiveness research in urology in 2016.

Epithelial ovarian cancer mortality among Hispanic women: Sub-ethnic disparities and survival trend across time: An analysis of SEER 1992-2013

BACKGROUND

Over the past half century the proportion of Hispanics in the US population has been steadily increasing, and groups of Hispanic origin have diversified. Despite notable racial and ethnic disparities in ovarian cancer (OC) mortality, population-based studies on OC among Hispanic females are lacking.

OBJECTIVES

To examine sub-ethnic disparities in OC mortality and survival trends using the Surveillance, Epidemiology, and End Results Program (SEER) 18 data on Hispanic women diagnosed with epithelial OC during 1992-2013.

METHODS

The disparities in OC 5 year survival and mortality were examined using log-rank tests and Cox proportional hazards models, adjusted for sociodemographic and pathological characteristics, time of diagnosis, receipt of resection surgery and county socioeconomic status. Trends in 5-year survival rates were examined using joinpoint regression models.

RESULTS

The 5-year survival was lowest in Puerto Ricans (median survival: 33 months; survival rate: 31.07%) and was highest in the "Other" Hispanic subgroup (median survival: 59 months; survival rate: 49.14%) (log-rank test: P < 0.001). The OC-specific death hazards in Mexicans (HRadj: 0.82, 95%CI: 0.67-1.00, P = 0.048), South or Central Americans (HRadj: 0.77, 95%CI: 0.62-0.96, P = 0.005) and Other Hispanics (HRadj: 0.76, 95%CI: 0.63-0.92, P = 0.038) were significantly lower than for Puerto Ricans. Mortality rates of Cubans and Puerto Ricans were not significantly different. During 1992-2008, there were non-significant increasing trends in the 5-year all-cause and OC-specific survival rates: from 43.37% to 48.94% (APC = 0.41, P = 0.40) and from 48.72% to 53.46% (APC = 0.29, P = 0.50), respectively.

CONCLUSIONS

OC mortality in Hispanic patients varied by sub-ethnicity. This heterogeneity should be considered in future cancer data collection, reports and research.

Balancing Confounding and Generalizability Using Observational, Real-world Data: 17-gene Genomic Prostate Score Assay Effect on Active Surveillance

Randomized, controlled trials can provide high-quality, unbiased evidence for therapeutic interventions but are not always a practical or viable study design for certain healthcare decisions, such as those involving prognostic or predictive testing. Studies using large, real-world databases may be more appropriate and more generalizable to the intended target population of physicians and patients to answer these questions but carry potential for hidden bias. We illustrate several emerging methods of analyzing observational studies using propensity score matching (PSM) and coarsened exact matching (CEM). These advanced statistical methods are intended to reveal a "hidden experiment" within an observational database, and so refute or confirm a potential causal effect of assignment to an intervention and study outcome. We applied these methods to the Optum™ Research Database (ORD; Eden Prairie, MN) of electronic health records and administrative claims data to assess the effect of the 17-gene Genomic Prostate Score® (GPS™; Genomic Health, Redwood City, CA) assay on use of active surveillance (AS). In a traditional multivariable logistic regression, the GPS assay increased the use of AS by 29% (95% CI, 24%-33%). Upon applying the matching methods, the effect of the GPS assay on AS use varied between 27% and 80% and the matched data were significant among all algorithms. All matching algorithms performed well in identifying matched data that improved the imbalance in baseline covariates. By using different matching methods to assess causal inference in an observational database, we provide further confidence that the effect of the GPS assay on AS use is statistically significant and unlikely to be a result of confounding due to differences in baseline characteristics of the patients or the settings in which they were seen.

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.

Underutilization of Radical Cystectomy Among Patients Diagnosed with Clinical Stage T2 Muscle-invasive Bladder Cancer

BACKGROUND

Radical cystectomy is the standard surgical treatment for muscle-invasive bladder cancer (MIBC).

OBJECTIVE

We sought to identify population-based factors predicting the use of radical cystectomy.

DESIGN, SETTING, AND PATIENTS

Analysis of Surveillance, Epidemiology, and End Results (SEER)-Medicare data for 3922 patients aged ≥66 yr diagnosed with clinical stage T2 MIBC from January 1, 2002 to December 31, 2011.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We used univariate and multivariable regression analyses to identify factors predicting the use of radical cystectomy. Cox proportional hazards models were used to analyze survival outcomes.

RESULTS AND LIMITATIONS

A total of 740 (18.9%) patients with MIBC underwent radical cystectomy. Older age at diagnosis (>80 vs 65-69 yr, odds ratio [OR] 0.15, 95% confidence interval [CI] 0.11-0.19; p<0.001) and higher comorbidity (Charlson comorbidity index 3+ vs 0, OR 0.41, 95% CI 0.29-0.57; p<0.001) were associated with lower use of radical cystectomy. Moreover, non-Hispanic black patients were less likely than white patients to undergo radical cystectomy (OR 0.62, 95% CI 0.40-0.96; p=0.032) and pelvic lymph node dissection (OR 0.65, 95% CI 0.42-1.02; p=0.058). Overall survival was better for patients who underwent radical cystectomy alone (hazard ratio [HR] 0.70, 95% CI 0.56-0.88; p=0.002) and with lymph node dissection (HR 0.45, 95% CI 0.40-0.51; p<0.001). Limitations include the limited ability of retrospective analysis to demonstrate causality.

CONCLUSIONS

There is significant underutilization of radical cystectomy among patients diagnosed with MIBC, especially among older patients with significant comorbidities and non-Hispanic black patients.

PATIENT SUMMARY

Despite guideline recommendations, there is significant underutilization of radical cystectomy among patients diagnosed with bladder cancer, especially for non-Hispanic black patients and older patients with significant comorbidities.