Prostate Cancer Outcomes by Race & Treatment Site

Can-lan Sun MD PhD, Smita Bhatia MD MPH, Lennie Wong PhD,Gail Washington DNS, Karen Nielsen-Menicucci PhD

12/11/2008

2008 Estimated US Cancer Deaths*

ONS=Other nervous system.Source: American Cancer Society, 2008.

Men294,120Lung & bronchus 31%

Prostate 10%

Colon & rectum 8%

Pancreas 6%

Liver & intrahepatic bile duct 4%

Leukemia 4%

Esophagus 4%

Urinary bladder 3%

Non-Hodgkin lymphoma 3%

Kidney & renal pelvis 3%

All other sites 24%

Cancer Death Rates* by Sex, US, 1975-2004

*Age-adjusted to the 2000 US standard population.Source: Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov) SEER*Stat Database: Mortality - All COD, Public-Use With State, Total U.S. (1969-2004), National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch, released April 2007. Underlying mortality data provided by NCHS (www.cdc.gov/nchs).

0

50

100

150

200

250

300

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002

Men

Both Sexes

Rate Per 100,000

Women

Cancer Death Rates* Among Men, US,1930-2004

*Age-adjusted to the 2000 US standard population.Source: US Mortality Data 1960-2004, US Mortality Volumes 1930-1959,National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.

0

20

40

60

80

10019

30

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

Rate Per 100,000

Prostate

Prostate Cancer Mortality Rates in the US, 1969-2004

6

22.6

18.5

53.3

10.4

17.6

African Americans are twice as likely than Whites to die of prostate cancer.

Note: Data are age adjusted to the 2000 standard population. SOURCE: National Cancer Institute, Surveillence, Epidemiology, and End Results (SEER) Program; National Vital Statistics System--Mortality, NCHS, CDC.

Prostate Cancer Death Rates, 2005Prostate Cancer Death Rates, 2005Per 100,000 population

White, Non-Hispanic

Hispanic

African American, Non-Hispanic

Asian and Pacific Islander

American Indian/Alaska Native

Dea

ths

Dea

ths

Why?

More aggressive tumors

More advanced stage at diagnosis

Health insurance and access to care

Difference in screening-early detection

Differences in receiving optimal treatment

Socioeconomic status

Healthcare provider

Aims

Aim 1: Compare mortality rates between African-Americans and Caucasians with newly diagnosed prostate cancer in Los Angeles County after controlling for age, SES, marital status, stage, grade, insurance, and treatment modality.

Aim 2: Compare the mortality rates for prostate cancer between NCI designated comprehensive cancer centers and other treatment facilities in Los Angeles County.

Aim 3: Compare the mortality rates by race for patients with prostate cancer receiving care within NCI cancer centers

Aim 4: Describe the proportion of African-Americans and Caucasians seeking treatment for newly diagnosed prostate cancer at NCI designated cancer centers and other treatment facilities, and understand the role of socioeconomic and insurance status in accessing care at the NCI-designated cancer centers versus other treatment facilities

Data Sources

Los Angeles Cancer Surveillance Program (CSP) White or African-American Diagnosed with prostate cancer 1998-2003

NCI-designated Cancer Center USC-Norris Cancer Center, UCLA-Jonsson Cancer Center,

City of Hope Cancer Center

Office of State Health Planning Department (OSHPD): Teaching status Bed Size Average length of stay Urban vs. Rural Hospital in-patient racial distribution MSSA: % below poverty, racial distribution

Variables

Outcomes

Overall mortality

Prostate cancer-specific mortality

Time to event (in years from the date of diagnosis to date of death or last known date)

Main Exposure

Race: White vs. African-American

NCI designated Cancer Center vs. other non-NCI

designated treatment facilities

Variables

Adjustment variables: Demographics

• SES, age, marital status

Year of diagnosis: 1998-2003

Insurance Tumor information

• Stage (localized, regional, distant)• Grade (well-differentiated, moderately

differentiated, poor/undifferentiated)

Treatment information• Surgery (no, radical/total prostatectomy) • Radiation (yes, no)• Hormone therapy (yes, no)

Preliminary Results

24,360

22886

21426

19817

19309

19298

18984

18,790

Unknown Grade-1474

Unknown Stage-1460

Unknown surgery-1609

Unknown hormone-508

Unknown radiation-11

Unknown Insurance-314

Unknown SES-194

Comparison: White vs. AA

White

N=14, 579

AA

N=4211

Alive 11856 (81%) 3328 (79%)

Dead 2723 (19%) 883 (21%)*

prostate-specific 543 (4%) 200 (5%)*

other 2180 (15%) 683 (16%)*

*P <0.05

Comparison: White vs. AA

White AA

Age at Dx 68 (16-99) 64 (33-93)*

Stage

Local 12831 (88.0%) 3708 (88.1%)

Regional 1290 (8.9%)) 286 (6.8%)*

Distant 458 (3.1%) 217 (5.1%)*

Grade

Well-differentiated 525 (3.6%) 151 (3.6%)

Moderately differentiated 10932 (75.0%) 3177 (75.4%)

Poor/undifferentiated 3122 (21.4%) 883 (21.0%)

*P<0.05

Comparison: White vs. AA

White AA

Treatment Watchful waiting 2284 (15.7%) 925 (20.0%)*

Surgery only 5419 (37.2%) 1420 (33.7%)*

Hormone only 1759 (12.1%) 561 (13.3%)

Radiation only 2371 (16.2%) 691 (16.4%)

Combination of Surgery /hormone /radiation

2746 (18.8%) 614 (14.6%)*

*P<0.05

Comparison: White vs. AA

White AA

SES 1 (highest) 6499 (44.6%) 568 (13.5%)*

2 3667 (25.1%) 719 (17.1%)*

3 2464 (16.9%) 897 (21.3%)*

4 1383 (9.5%) 1072 (25.4%)*

5 (lowest) 566 (3.9%) 955 (22.7%)*

*P<0.05

Comparison: White vs. AA

White AA

Insurance no 211 (1.5%) 195 (4.6%)*

Insurance NOS 806 (5.5%) 144 (3.4%)*

Managed care, HMO PPO 7977 (54.7%) 2329 (55.3%)

Medicare 2781 (19.1%) 439 (10.4%)*

Military, Veterinarian, PHS 290 (2.0%) 251 (6.0%)*

County funded 2514 (17.2%) 853 (20.3%)*

Specific Aim 1

Compare mortality rates between African-Americans and Caucasians with newly diagnosed prostate cancer in Los Angeles County

Overall and Prostate-specific Mortality:White vs. AA

60%

70%

80%

90%

100%

0 1 2 3 4 5 6 7 8 9 10Years after Diagnosis

Sur

viva

l (%

)

PC WhitePC AAOverall WhiteOverrall AA

Overall Mortality P<0.001

Prostate-specificP=0.002

Specific Aim 2

Compare the mortality rates for prostate cancer between NCI-designated Cancer Centers and other treatment facilities in Los Angeles County

Overall and Prostate-specific Mortality: NCI designated comprehensive cancer centers

vs. other treatment facilities

60%

70%

80%

90%

100%

0 1 2 3 4 5 6 7 8 9 10

Years after Diagnosis

Su

rviv

al (

%)

PC NCIPC Non-NCIOverall NCIOverall non-NCI

Prostate-specificP<0.001

Overall mortality P<0.001

Specific Aim 3

Compare the mortality rates by race for patients with prostate cancer receiving care within NCI-designated Cancer Centers

Overall and Prostate-specific Mortality: by Race among patients treated at NCI Cancer Centers

70%

80%

90%

100%

0 1 2 3 4 5 6 7 8 9 10Years after Diagnosis

Su

rviv

al (

%)

PC NCI AAPC NCI White

overall NCI AAOverall NC Wwhite

Prostate-specific P=0.52

Overall Mortality P=0.17

Multivariate analysis

• Aim 1: Compare mortality rates between African-Americans and Caucasians with newly diagnosed prostate cancer in Los Angeles County after controlling for age, SES, stage, grade, insurance, and treatment modality.

Overall mortality: AA vs. White

0.630.68 0.64 0.66

0.74

0.44

0.59

0

1

Univariate + Age + Race + SES + Grade/Stage + Insurance + Treatment

HR

(9

5%

CI)

Prostate-specific mortality: AA vs. White

1.241.17 1.17 1.13 1.11

1.55

1.32

0

1

Univariate + Age + SES + Grade/Stage + Insurance + Treatment + NCI

HR

(95%

CI)

Multivariate analysis

• Aim 2: Compare mortality rates for prostate cancer between NCI designated comprehensive cancer centers and other treatment facilities in Los Angeles County.

Overall mortality: NCI vs. non-NCI

0.630.68 0.64 0.66

0.74

0.44

0.59

0

1

Univariate + Age + Race + SES + Grade/Stage + Insurance + Treatment

HR

(9

5%

CI)

Prostate-specific mortality: NCI vs. non-NCI

0.640.69

0.59 0.610.69

0.59

0.47

0

1

Univariate + Age + Race + SES + Grade/Stage + Insurance + Treatment

HR

(95%

CI)

Multivariate analysis

Aim 3: Compare mortality rates by race for patients with prostate cancer receiving care within NCI-designated Cancer Centers

Due to the small number of AA receiving care at NCI-designated cancer centers, we were unable to perform this analysis.

Specific Aim 4

Aim 4: Understand the role of sociodemographic factors in accessing care at the NCI-designated treatment centers versus non-NCI centers

Non-NCI NCI OR

Race

White

12933 (88.7%)

1646 (11.3%)

1.00

AA 4063 (96.5%) 148 (3.5%) 0.29 (0.24-0.34)

Utilization of NCI-designated Cancer Center

Utilization of NCI Cancer Centers: AA vs. White

0.38 0.39 0.4 0.40 0.42 0.420.45

0.29

0

1

Univariate + SES + Age + Insurance + Maritalstatus

+Stage/Grade

+ Treatment + Year of dx

HR

(95%

CI)

Utilization of NCI-designated Cancer Center

OR (95% CI)

AA vs. White 0.42 (0.35-0.50)

Age at diagnosis (years) 0.95 (0.94-0.95)

SES =1 highest

SES =2 0.61 (0.53-0.69)

SES =3 0.41 (0.35-0.49)

SES =4 0.37 (0.30-0.46)

SES =5 lowest 0.30 (0.22-0.42)

Insurance: no 1.00

Insurance NOS 2.55 (1.58-4.12)

Managed care HMO PPO 1.05 (0.67-1.66)

Medicare 3.22 (2.01-5.13)

County 0.08 (0.02-0.34)

Military/veteran/ PHS 2.12 (1.32-3.40)

Utilization of NCI-designated Cancer Center

OR (95% CI)

Grade: well-differentiated 1.00

Moderately differentiated 3.11 (1.87-5.18)

Poor/undifferentiated 3.79 (2.25-6.36)

Stage: localized 1.00

Regional 1.29 (1.10-1.51)

Distant 1.12 (0.75-1.65)

Treatment: watchful waiting 1.00

Surgery only 2.65 (2.16-3.25)

Hormone only 0.80 (0.59-1.09)

Radiation only 1.04 (0.81-1.33)

Multiple 1.36 (1.09-1.70)

Year of Dx (more recent years) 1.06 (1.03-1.10)

Conclusion

AA have a higher overall and prostate-specific mortality on univariate analysis

AA have comparable overall and prostate specific mortality to Whites after adjustment for sociodemographic factors, tumor characteristic, treatment modality, and treatment site

NCI-designated cancer centers have lower overall and prostate specific mortality compared to non-NCI treatment facilities

This difference persists after adjustment for all clinical and sociodemographic factors

Within NCI-designated cancer centers, AA have comparable overall and prostate-specific mortality to Whites Within the constraints of the limited sample size

AA are less likely to use NCI-designated Cancer Centers Independent of SES, insurance, and tumor factors

Future Plans (Year 02)

Current data set demonstrates that only 148 AA utilized the 3 NCI-designated Cancer Centers in LAC

Expand the scope of analysis Obtain data from CSP for 1976 to 2003

Explore the reasons of inferior outcomes at non-NCI designated Cancer Centers Data from Office of Statewide Health Planning and

Development.• Secondary quality indicators• Teaching status, bed size, hospital in-patient average stay, MSSA

poverty, racial distribution,

Thank you!

Does Treatment Site really make a difference?

In-hospital short-term mortality after Prostatectomy

High volume of prostectomies associated with low mortality

• Medicare claims data

• n=101,604 between 1991 and 1994

• Nationwide Inpatient Sample

• n=66,693 between 1989-1995

Yao, S.L. and G. Lu-Yao, Population-based study of relationships between hospital volume of prostatectomies, patient outcomes, and length of hospital stay. J Natl Cancer Inst, 1999. 91(22): p. 1950-6.

Ellison, L.M., J.A. Heaney, and J.D. Birkmeyer, The effect of hospital volume on mortality and resource use after radical prostatectomy. J Urol, 2000. 163(3): p. 867-9.

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

NCI-Designation

Medicare database Mortality after cystectomy, colectomy,

pulmonary resections, pancreatic resection, gastrectomy and esophagectomy

NCI Centers had lower operative mortality in 4/6 procedures

Long term mortality: no difference

Birkmeyer, N.J., et al., Do cancer centers designated by the National Cancer Institute have better surgical outcomes? Cancer, 2005. 103(3): p. 435-41.

Overall HR Prostate-specific HR

AA vs. White 1.08 (0.99-1.17) 1.12 (0.93-1.35)

NCI center vs. non-NCI 0.75 (0.64-0.88) 0.69 (0.49-0.97)

Age at diagnosis (years) 1.05 (1.04-1.06) 1.02 (1.01-1.03)

SES =1 highest 1.00 1.00

SES =2 1.21 (1.10-1.33) 1.08 (0.87-1.33)

SES =3 1.33 (1.21-1.47) 1.26 (1.02-1.55)

SES =4 1.37 (1.23-1.52) 1.15 (0.91-1.46)

SES =5 lowest 1.46 (1.29-1.66) 1.29 (0.99-1.68)

No Insurance: 1.00

Insurance NOS 0.53 (0.39-0.71) 0.46 (0.25-0.84)

HMO PPO 0.84 (0.67-1.05) 0.91 (0.60-1.39)

Medicare 0.86 (0.68-1.08) 0.82 (0.53-1.28)

Military/Vet/ Indian/PHS 0.80 (0.61-1.06) 0.70 (0.40-1.22)

County funded 0.82 (0.65-1.03) 0.74 (0.48-1.15)

Overall HR Prostate-specific HR

Grade: well-differentiated 1.00 1.00

Moderately differentiated 1.08 (0.91-1.28) 1.68 (0.91-3.07)

Poor/undifferentiated 1.69 (1.42-2.01) 4.87 (2.66-8.92)

Stage: localized 1.00 1.00

Regional 1.25 (1.07-1.38) 2.28 (1.76-2.94)

Distant 3.76 (3.38-4.18) 14.72 (12.21-17.76)

Treatment: watchful waiting 1.00

Surgery only 0.31 (0.28-0.35) 0.19 (0.13-0.27)

Hormone only 1.04 (0.95-1.15) 1.29 (1.05-1.60)

Radiation only 0.61 (0.55-0.68) 0.50 (0.36-0.70)

Multiple 0.67 (0.60-0.74) 0.86 (0.67-1.09)

Year of Dx 1.03 (1.01-1.06) 0.98 (0.93-1.03)