Prostate Cancer Outcomes by
 Race & Treatment Site
Drs. Kurian, Washington, Nielsen-Menicucci
An estimated 30,870 cases among AA in 2007
37% of all cancers in AA men
Between 2000-2003, The average annual prostate cancer incidence rate was 60% higher in AA than in white men

Racial Distribution of Prostate Cancer
This difference accounts for about 40% of the overall cancer mortality disparity between African American and white men.

Overall 5-year relative survival rate for prostate cancer among African Americans is 98% compared to 100% among whites.
80% of AAs are diagnosed in local or regional stages
So morbidity is an equally important outcome of interest.

Explanatory Theories
Biologic Hypothesis
Differences in susceptibility
Differences in tumor virulence
Access Hypothesis
Socioeconomic issues
Access to care

Environmental Issues
Dietary preferences among the races may account for differences in prostate cancer rates.

Oncology Health Disparities Model
Access to care
There seemed to be disparate findings in the literature about mortality outcomes after treatment for prostate cancer.
Single institution or multi-large center studies found that mortality was equivalent with equivalent treatment
Population based studies, do not support these findings.

Mortality Literature Review
Morbidity after Prostate Cancer
Type of Study
Erectile dysfunction after radical prostatectomy
Population-based studies : 53%-88%
Single Institution: 22%-90%
Erectile dysfunction after external beam radiation
Population-based studies: 23%-67%
Single Institution: 7%-63%
Erectile dysfunction after brachytherapy
Population-based studies: 8%
Single Institution: 16%-50%

Morbidity after Prostate Cancer
Similar variability noted in reporting of urinary and bowel symptoms.
Wide variations in reporting of morbidity between races.

"Hypothesis 1:"
Hypothesis 1: African-Americans with newly diagnosed prostate cancer have a higher incidence of mortality and morbidity compared to Caucasians after controlling for age, stage, grade and treatment modality
Hypothesis 2: Patients with newly diagnosed prostate cancer, receiving care at NCI designated Cancer Centers have a lower incidence of mortality and morbidity, irrespective of race and ethnicity, when compared with those treated at non-NCI cancer centers.
Hypothesis 3: African-Americans and Caucasians receiving care at NCI-designated cancer centers have comparable mortality and morbidity.
Hypothesis 4: Proportionately fewer African-Americans utilize NCI cancer centers when compared to Caucasians.

Does Where You Get Treatment really make a difference?
Mortality in General:
Volume seems to make a difference
Supported by lit review of 135 studies
Cohort study using SEER data
Mortality After Prostate Cancer
Volume seems to make a difference
Review of 101,604 Medicare claims data
Nationwide Inpatient Sample
Prostatectomies between 1989-1995

Does Where You Get Treatment really make a difference?
Morbidity after Prostate Cancer
Volume linked to decreased rates of postoperative and late urinary complications
Participation in clinical trials
Use of specialist to staff intensive care units
High nurse-to-bed ratios

Does NCI designation exert an effect on outcomes ?
National Cancer Act
Establish regional centers of excellence in research and patient care.
To be NCI designated
Excellence in Research
Excellence in Cancer Prevention
Excellence in Clinical Services.

One study using Medicare database
Mortality after cystectomy, colectomy, pulmonary resections, pancreatic resection, gastrectomy and esophagectomy
NCI Centers had lower operative mortality in 4/6 procedures
NCI Centers had lower overall mortality in 2/6 procedures.

Does Utilization of Care Differ between Blacks and Whites
Disparities exist in a variety of health service categories
Range from pediatric/ maternal and child health to rehabiliatative and nursing home services.
Disparities in care resulted in disparities in mortality

Does Utilization of Care Differ between Blacks and Whites (Prostate Cancer)
More likely to receive conservative management
More likely to receive orchiectomy rather than expensive hormonal drug treatments

Racial differences in the use of centers of excellence
Only one study
utilization of high-volume hospitals for complex surgery
overall non-whites, Medicaid patients and uninsured patients were less likely to receive care at high-volume hospitals
No studies looking at differences in the use of NCI designated centers

Data Sources
California Cancer Registry
Race, SES, census tract, age, marital status, zip code
Tumor information
Stage, grade
Treatment information
Surgery, radiation, hormone therapy, location of therapy, NCI status of institution,
Vital Status

Data Sources
Office of Statewide Health Planning and Development.
Secondary quality indicators
Teaching status, bed size, hospital location
Morbidity information

Expanded Prostate Cancer Index Composite
designed to evaluate patient function and bother after prostate cancer treatment
evaluated in the domains of urinary function, bowel habits, sexual function and hormonal function

EPIC supplement
Will ask patients to indicate when they first noticed symptoms and when these symptoms resolved.
Allows us to make some inference regarding the effect of treatment on the development of the morbidity

Symptom Schedule
Patient Population
All African-American (N=5,215) and non-Hispanic Caucasian (n=16,789) cases with newly diagnosed prostate cancer reported to the CSP from 1998-2003.
All African-American patients with newly diagnosed prostate cancer reported to the CSP between January 2002 and December 2003 (n=1,619) as well as a set of non-Hispanic Caucasian cases (n=2,581) randomly sampled to match the frequencies for age, disease stage and grade in the African-American cohort

Supplementary Studies
Impact of distance from NCI center
Using GIS and location of patient, treatment, reporting hospitals and nearest NCI center
Effect of other quality indicators such as teaching status, bed size and possibly volume on mortality and morbidity.