The impact of racial residential segregation on prostate cancer diagnosis and treatment

OBJECTIVES

To examine the effects of racial residential segregation and structural racism on the diagnosis, treatment, and outcomes of patients with prostate cancer.

PATIENTS AND METHODS

This retrospective cohort study examined men diagnosed with prostate cancer between 2005 and 2015. We collected data from Black and White men, aged ≥30 years, living within the 100 most populous counties participating in the Surveillance, Epidemiology, and End Results programme, a nationally representative dataset. The racial Index of Dissimilarity, a validated measure of segregation, was the primary exposure of interest. Outcomes of interest included advanced stage at diagnosis (Stage IV), surgery for localised disease (Stage I-II), and 10-year overall and cancer-specific survival. Multivariable Poisson regression analyses with robust error variance estimated the relative risk (RR) of advanced stage at diagnosis and surgery for localised disease at differing levels of segregation. Survival analysis was performed using competing hazards analysis.

RESULTS

Multivariable models estimating stage at diagnosis showed that the disparities between Black and White men disappeared at low levels of segregation. Disparities in receiving surgery for localised disease persisted across all levels of segregation. In racially stratified analyses, segregation had no effect on stage at diagnosis or surgical resection for Black patients. White patients saw a 56% (RR 0.42, P < 0.001) reduced risk of presenting at advanced stage and 20% increased likelihood (RR 1.20, P < 0.001) of surgery for localised disease. Black patients in the lowest segregation areas had the lowest overall mortality, but the highest cancer-specific mortality.

CONCLUSIONS

Our study provides evidence that residential segregation has a significant impact on Black-White disparities in prostate cancer, likely through improved outcomes for White patients and worse outcomes for Black patients in more segregated areas. These findings suggest that mitigating segregation and the downstream effects of socioeconomic factors could alleviate these disparities.

Racial disparities in clinical presentation, type of intervention, and in-hospital outcomes of patients with metastatic spine disease: An analysis of 145,809 admissions in the United States

BACKGROUND

Race is an important determinant of cancer outcome. The purpose of this study was to identify disparities in clinical presentation, treatment use, and in-hospital outcomes of patients with spinal metastases.

METHODS

The United States National Inpatient Sample database (2004-2014) was queried to identify patients with metastatic disease and cord compression (MSCC) or spinal pathological fracture. Clinical presentation, type of intervention, and in-hospital outcomes were compared between races/ethnicities. Multivariate logistic regression analyses were performed and adjusted for differences in patient age, sex, insurance status, income quartile, hospital teaching status and size, Charlson comorbidity index, smoking status, tumor type, and neurological status.

RESULTS

A total of 145,809 patients were identified - 74.8 % Caucasian, 14.1 % African-American, 7.9 % Hispanic, and 3.2 % Asian. Over one-third of patients (38.1 %) presented with MSCC; 35.7 % of Caucasians, 50.3 % of AAs, 41.1 % of Hispanics, and 39.8 % of Asians (p < 0.001). Paralysis affected 8.4 % of all patients; 7.4 % of Caucasians, 12.7 % of AAs, 10.5 % of Hispanics, and 10.0 % of Asians (p < 0.001). For patients with MSCC, multivariate analysis showed that AAs were less likely to undergo surgical intervention (OR 0.71; 95 % CI, 0.62 - 0.82; p < 0.001), significantly more likely to experience a complication (OR 1.25; 95 % CI, 1.12-1.40; p < 0.001), significantly more likely to experience prolonged length of stay (OR 1.22; 95 % CI, 1.08-1.36; p = 0.001), and significantly more likely to experience a non-routine discharge (OR 1.19; 95 % CI, 1.05-1.35; p = 0.007) compared to Caucasians.

CONCLUSION

Minority groups with spinal metastatic disease may be at a disadvantage compared to Caucasians, with significant disparities found in presenting characteristics, type of intervention, and in-hospital outcomes. Continued efforts to overcome these differences are needed.

Spatial patterns in prostate Cancer-specific mortality in Pennsylvania using Pennsylvania Cancer registry data, 2004-2014

BACKGROUND

Spatial heterogeneity of prostate cancer-specific mortality in Pennsylvania remains unclear. We utilized advanced geospatial survival regressions to examine spatial variation of prostate cancer-specific mortality in PA and evaluate potential effects of individual- and county-level risk factors.

METHODS

Prostate cancer cases, aged ≥40 years, were identified in the 2004-2014 Pennsylvania Cancer Registry. The 2018 County Health Rankings data and the 2014 U.S. Environmental Protection Agency's Environmental Quality Index were used to extract county-level data. The accelerated failure time models with spatial frailties for geographical correlations were used to assess prostate cancer-specific mortality rates for Pennsylvania and by the Penn State Cancer Institute (PSCI) 28-county catchment area. Secondary assessment based on estimated spatial frailties was conducted to identify potential health and environmental risk factors for mortality.

RESULTS

There were 94,274 cases included. The 5-year survival rate in PA was 82% (95% confidence interval, CI: 81.1-82.8%), with the catchment area having a lower survival rate 81% (95% CI: 79.5-82.6%) compared to the non-catchment area rate of 82.3% (95% CI: 81.4-83.2%). Black men, uninsured, more aggressive prostate cancer, rural and urban Appalachia, positive lymph nodes, and no definitive treatment were associated with lower survival. Several county-level health (i.e., poor physical activity) and environmental factors in air and land (i.e., defoliate chemical applied) were associated with higher mortality rates.

CONCLUSIONS

Spatial variations in prostate cancer-specific mortality rates exist in Pennsylvania with a higher risk in the PSCI's catchment area, in particular, rural-Appalachia. County-level health and environmental factors may contribute to spatial heterogeneity in prostate cancer-specific mortality.

Temporal and spatial trends and determinants of aggressive prostate cancer among Black and White men with prostate cancer

PURPOSE

Few studies have reported temporal and spatial trends of aggressive prostate cancer (PC) among black men who are known to have more aggressive disease. We examined these trends for highly aggressive PC at diagnosis among black and white men in Pennsylvania (PA).

METHODS

Men, aged ≥ 40 years, with a primary, clinical PC diagnosis were identified from the Pennsylvania Cancer Registry, 2004-2014. Joinpoint analysis was used to evaluate the temporal trend of highly aggressive PC (clinical/pathologic Gleason score ≥ 7 [4 + 3], clinical/pathologic tumor stage ≥ T3, or distant metastasis) and identify change points by race in which annual percent change (APC) was calculated. Logistic regression analyses were used to examine the association between race and highly aggressive PC, after adjusting for covariates with and without spatial dependence.

RESULTS

There were 89,133 PC cases, which included 88.7% white and 11.3% black men. The APC of highly aggressive PC was 8.7% from 2011 to 2014 among white men and 3.6% from 2007 to 2014 among black men (p values ≤ 0.01). The greatest odds of having highly aggressive PC among black compared to white men were found in counties where the black male population was ≤ 5.3%.

CONCLUSIONS

Highly aggressive PC increased for both black and white men in PA between 2004 and 2014. Black men had more aggressive disease, with the greatest odds in counties where the black male population was small. The increase in highly aggressive PC may be due to less screening for PC, resulting in more advanced disease at diagnosis.

Differential use of medical versus surgical androgen deprivation therapy for patients with metastatic prostate cancer

BACKGROUND

Surgical and medical androgen deprivation therapy (ADT) strategies are comparable in their ability to suppress serum testosterone levels as treatment in patients with metastatic prostate cancer but differ with regard to cost and impact on quality of life. Medical ADT is associated with better long-term quality of life due to the flexibility of possible therapy interruption but comes with a higher cumulative cost. In the current study, the authors examined whether surgical ADT (ie, bilateral orchiectomy) was used differentially by race/ethnicity and other social factors.

METHODS

The authors identified patients with metastatic disease at the time of diagnosis through the California Cancer Registry. The association between race/ethnicity and receipt of surgical ADT was modeled using multivariable Firth logistic regression adjusting for age, Gleason score, prostate-specific antigen level, clinical tumor and lymph node classification, neighborhood socioeconomic status (SES), insurance, marital status, comorbidities, initial treatment (radiotherapy, chemotherapy), location of care, rural/urban area of residence, and year of diagnosis.

RESULTS

The authors examined a total of 10,675 patients with metastatic prostate cancer, 11.4% of whom were non-Hispanic black, 8.4% of whom were Asian/Pacific Islander, 18.5% of whom were Hispanic/Latino, and 60.5% of whom were non-Hispanic white. In the multivariable model, patients found to be more likely to receive surgical ADT were Hispanic/Latino (odds ratio [OR], 1.32; 95% confidence interval [95% CI], 1.01-1.72), were from a low neighborhood SES (OR, 1.96; 95% CI, 1.34-2.89) or rural area (OR, 1.49; 95% CI, 1.15-1.92), and had Medicaid/public insurance (OR, 2.21; 95% CI, 1.58-3.10). Patients with military/Veterans Affairs insurance were significantly less likely to receive surgical ADT compared with patients with private insurance (OR, 0.34; 95% CI, 0.13-0.88).

CONCLUSIONS

Race/ethnicity, neighborhood SES, and insurance status appear to be significantly associated with receipt of surgical ADT. Future research will need to characterize other differences in initial treatments among men with advanced prostate cancer based on race/ethnicity and aim to better understand what factors drive the association between surgical ADT among men of Hispanic origin or those from areas with low neighborhood SES.

Tobacco smoking and survival after a prostate cancer diagnosis: A systematic review and meta-analysis

BACKGROUND

While a number of studies indicate tobacco smoking has a detrimental impact on survival and recurrence after a prostate cancer diagnosis, there has been no quantitative review of this literature and it is unclear whether tobacco smoking affects clinical populations differentially. We conducted a systematic review and meta-analysis to investigate the associations between tobacco smoking and overall (OM) and prostate cancer-specific (PSM) mortality and recurrence after a prostate cancer diagnosis.

METHODS

EMBASE and ISI Web of Science were searched for English-language studies, published up to August 17, 2017, which conducted a survival analysis to estimate the association between tobacco smoking and OM, PSM and/or recurrence. A random-effects meta-analysis was conducted to estimate the summary hazard ratios (HRs) for the associations between tobacco smoking and the three outcomes.

RESULTS

A total of 28 studies met the inclusion criteria. The results of the primary meta-analysis indicate current smokers have significantly poorer overall survival (Summary HR = 1.96, 95% CI = 1.69, 2.28), prostate cancer-specific survival (Summary HR = 1.79, 95% CI = 1.47, 2.20) and recurrence-free survival (Summary HR = 1.48, 95% CI = 1.28, 1.72) than never smokers. Similar results were found in population-based studies and in studies conducted in specific clinical populations.

CONCLUSIONS

The results of this systematic review and meta-analysis indicate that tobacco smoking at prostate cancer diagnosis is associated with a significantly increased risk of overall mortality, prostate-cancer specific mortality and recurrence. We recommend future studies collect more detailed information about tobacco smoking to further understanding of the association between tobacco smoking and PCa prognosis. In addition, further research should concentrate on the impact of smoking cessation post-diagnosis and post-treatment on prognosis, and the feasibility and effectiveness of smoking cessation programs.

Racial/ethnic disparities in de novo metastases sites and survival outcomes for patients with primary breast, colorectal, and prostate cancer

Racial disparities in cancer mortality still exist despite improvements in treatment strategies leading to improved survival for many cancer types. In this study, we described race/ethnic differences in patterns of de novo metastasis and evaluated the association between site of de novo metastasis and breast, prostate, and colorectal cancer mortality. Data were obtained from the Surveillance Epidemiology and Ends Results (SEER) database from 2010 to 2013 and included 520,147 patients ages ≥40 years with primary diagnosis of breast, colorectal, or prostate cancer. Site and frequency of de novo metastases to four sites (bone, brain, liver, and lung) were compared by race/ethnicity using descriptive statistics, and survival differences examined using extended Cox regression models in SAS 9.4. Overall, non‐Hispanic (NH) Blacks (11%) were more likely to present with de novo metastasis compared with NH‐Whites (9%) or Hispanics (10%). Among patients with breast cancer, NH‐Blacks were more likely to have metastasis to the bone, (OR: 1.25, 95% CI: 1.15–1.37), brain (OR: 2.26, 95% CI: 1.57–3.25), or liver (OR: 1.62, 95% CI: 1.35–1.93), while Hispanics were less likely to have metastasis to the liver (OR: 0.76, 95% CI: 0.60–0.97) compared with NH‐Whites. Among patients with prostate cancer, NH‐Blacks (1.39, 95% CI: 1.31–1.48) and Hispanics (1.39, 95% CI: 1.29–1.49) were more likely to have metastasis to the bone. Metastasis to any of the four sites evaluated increased overall mortality by threefold (for breast cancer and metastasis to bone) to 17‐fold (for prostate cancer and metastasis to liver). Racial disparities in mortality remained after adjusting for metastasis site in all cancer types evaluated. De novo metastasis is a major contributor to cancer mortality in USA with racial differences in the site, frequency, and associated survival.

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.

Beliefs Regarding Prostate Cancer Screening Among Black Males Aged 18 to 40 Years

This study was conducted to identify the salient behavioral beliefs of young Black men toward prostate cancer screening, and to identify the issues surrounding their comfortability with prostate examinations. A total of 20 Black men, aged between 18 and 40 years, participated in three focus group sessions between June 2013 and July 2013 in Austin, Texas. Participants were asked open-ended questions about: (a) the advantages and disadvantages of screening to identify salient behavioral beliefs about screening and (b) issues that would make prostate examinations comfortable or uncomfortable to identify comfortability factors. Focus group discussions were tape-recorded, transcribed, and content analyzed to identify emerging themes of salient beliefs and comfortability. Also, nine salient behavioral beliefs toward prostate cancer screening were identified, and eight factors were linked to comfortability with prostate examinations. Given the increase of prostate cancer disparity as a public health issue, understanding the beliefs of Black men of prescreening age (18-40 years) may be crucial to the effectiveness of future interventions to improve screening when recommended at later ages.

Patient demographic characteristics and disease stage as drivers of disparities in mortality in prostate cancer patients who receive care at a safety net academic medical center

INTRODUCTION

The purpose of this study was to examine the effect of patient demographic characteristics and tumor stage at diagnosis on mortality in prostate cancer patients who receive care at a safety net, academic medical center with a diverse patient population.

PATIENTS AND METHODS

Eight hundred sixty-nine patients were diagnosed with prostate cancer at our institution between August 2004 and October 2011. Patient demographic characteristics were determined as follows: race and/or ethnicity, primary language, insurance type, age at diagnosis, marital status, income (determined by zip code), and American Joint Committee on Cancer (AJCC) tumor stage. Fisher exact or Pearson χ(2) test was used to test for differences in categorical variables. Multivariate logistic regression analysis was performed to identify factors related to mortality recorded at the end of follow-up in March of 2012.

RESULTS

Mortality was significantly decreased in patients who spoke Haitian Creole (odds ratio [OR], 0.18; 95% confidence interval [CI], 0.04-0.74; P = .017). Distribution of insurance type, age, income, and prostate-specific antigen level differed between English and Haitian Creole speakers. Increased mortality was observed in patients who were single (OR, 1.99; 95% CI, 1.06-3.73; P = .032), older than 70 (OR, 15.5; 95% CI, 3.03-79.45; P = .001), had Medicaid and/or free care (OR, 4.98; 95% CI, 1.72-14.4; P = .003), or had AJCC stage IV cancer (OR, 9.56; 95% CI, 4.89-18.69; P < .001). There was no significant difference in mortality according to race and/or ethnicity or income in the multivariate-adjusted model.

CONCLUSION

In this retrospective study, prostate cancer patients who spoke Haitian Creole had a lower incidence of mortality compared with English speakers. Consistent with similar large-scale studies, being single or having Medicaid and/or free care insurance predicted worse outcomes, reinforcing their roles as drivers of disparities.