Nicola Fossati, Alessandro Larcher, Alberto Briganti, and Firas Abdollah
Nicola Fossati, Daniel P. Nguyen, Quoc-Dien Trinh, Jesse Sammon, Akshay Sood, Alessandro Larcher, Giorgio Guazzoni, Francesco Montorsi, Alberto Briganti, Mani Menon, and Firas Abdollah
Background: Approximately 15% of the US population does not have health insurance. The objective of this study was to evaluate the impact of insurance status on tumor characteristics and treatment selection in patients with prostate cancer. Materials and Methods: We identified 20,393 patients younger than 65 years with prostate cancer in the 2010–2011 SEER database. Multivariable logistic regression analysis tested the relationship between insurance status and 2 end points: (1) presenting with low-risk prostate cancer at diagnosis and (2) receiving local treatment of the prostate. Locally weighted scatterplot smoothing methods were used to graphically explore the interaction among insurance status, use of local treatment, and baseline risk of cancer recurrence. The latter was defined using the Stephenson nomogram and CAPRA score. Results: Overall, 18,993 patients (93%) were insured, 849 (4.2%) had Medicaid coverage, and 551 (2.7%) were uninsured. At multivariable analysis, Medicaid coverage (odds ratio [OR], 0.67; 95% CI, 0.57, 0.80; P<.0001) and uninsured status (OR, 0.57; 95% CI, 0.46, 0.71; P<.0001) were independent predictors of a lower probability of presenting with low-risk disease. Likewise, Medicaid coverage (OR, 0.72; 95% CI, 0.60, 0.86; P=.0003) and uninsured status (OR, 0.45; 95% CI, 0.37, 0.55; P<.0001) were independent predictors of a lower probability of receiving local treatment. In uninsured patients, treatment disparities became more pronounced as the baseline cancer recurrence risk increased (10% in low-risk patients vs 20% in high-risk patients). Conclusions: Medicaid beneficiaries and uninsured patients are diagnosed with higher-risk disease and are undertreated. The latter is more accentuated for patients with high-risk prostate cancer. This may seriously compromise the survival of these individuals.
Firas Abdollah, Jesse D. Sammon, Kaustav Majumder, Gally Reznor, Giorgio Gandaglia, Akshay Sood, Nathanael Hevelone, Adam S. Kibel, Paul L. Nguyen, Toni K. Choueiri, Kathy J. Selvaggi, Mani Menon, and Quoc-Dien Trinh
Objective: To examine racial disparities in end-of-life (EOL) care among black and white patients dying of prostate cancer (PCa). Methods: Relying on the SEER-Medicare database, 3789 patients who died of metastatic PCa between 1999 and 2009 were identified. Information was assessed regarding diagnostic care, therapeutic interventions, hospitalizations, intensive care unit (ICU) admissions, and emergency department visits in the last 12 months, 3 months, and 1 month of life. Logistic regression tested the relationship between race and the receipt of diagnostic care, therapeutic interventions, and high-intensity EOL care. Results: Overall, 729 patients (19.24%) were black. In the 12-months preceding death, laboratory tests (odds ratio [OR], 0.51; 95% CI, 0.36–0.72), prostate-specific antigen test (OR, 0.54; 95% CI, 0.43–0.67), cystourethroscopy (OR, 0.71; 95% CI, 0.56–0.90), imaging procedure (OR, 0.58; 95% CI, 0.41–0.81), hormonal therapy (OR, 0.53; 95% CI, 0.44–0.65), chemotherapy (OR, 0.59; 95% CI, 0.48–0.72), radiotherapy (OR, 0.74; 95% CI, 0.61–0.90), and office visit (OR, 0.38; 95% CI, 0.28–0.50) were less frequent in black versus white patients. Conversely, high-intensity EOL care, such as ICU admission (OR, 1.27; 95% CI, 1.04–1.58), inpatient admission (OR, 1.49; 95% CI, 1.09–2.05), and cardiopulmonary resuscitation (OR, 1.72; 95% CI, 1.40–2.11), was more frequent in black versus white patients. Similar trends for EOL care were observed at 3-month and 1-month end points. Conclusions: Although diagnostic and therapeutic interventions are less frequent in black patients with end-stage PCa, the rate of high-intensity and aggressive EOL care is higher in these individuals. These disparities may indicate that race plays an important role in the quality of care for men with end-stage PCa.