Prostate cancer (PCa) is the most common noncutaneous cancer and the second leading cause of cancer-related death in North American men.1 In the United States, 233,000 new cases of PCa are estimated to be diagnosed in 2014, along with 29,480 PCa-related deaths.1 Several patients with terminal metastatic PCa are confronted with difficult choices at both ends of the spectrum, ranging from aggressive end-of-the-line anticancer therapy to hospice care.
End-of-life (EOL) care represents a challenge for both the patient and the physician. The physician-patient, through honest and empathic communication, must decide when high-intensity care is no longer beneficial and when the goals of care shift to focus on continued intense symptom management and quality EOL care. Continued high-intensity care, including intensive care unit (ICU) admissions, emergency department (ED) visits, acute-care hospital visits, and use of new anticancer therapies very close to death, lead to unpropitious physical, psychological, and monetary effects at EOL.2–7
Despite the well-established disparities in quality of PCa care between white and black patients,8–12 how this relationship applies to EOL care in the context of advanced PCa is unclear. Qualitative research, across multiple cancers, suggests the existence of such disparities between white and black patients at EOL, with prior studies showing that black patients with end-stage cancers are at increased risk for receiving high-intensity EOL care relative to white patients.8–12 It has been hypothesized that this may be due to to the lack of awareness among black patients about palliative and hospice care, the prohibitive cost of care, a mistrust of the system, and poor physician-patient communication.13–17
However, none of these studies focused specifically on advanced PCa, which is usually known to be more frequent in black men.18 To address this void, we sought to examine the impact of race on the use of EOL resources, with emphasis on the use of high-intensity care among patients with PCa during the last year of life.
Materials and Methods
Data Source
Data originated from the NCI's SEER program of cancer registries that collect clinical, demographic, and cause of death information for persons with cancer in the United States. SEER dates were linked to data provided by the Center for Medicare & Medicaid Services (CMS) claims for covered health care services from the time of a person's Medicare eligibility until death. To link SEER and Medicare data, the participating SEER registries send individual identifiers for all persons in their files, which are matched with identifiers contained in Medicare's master enrollment file. For the linkage, 93% of men aged 65 years and older in the SEER files were matched with those in the Medicare enrollment file.19
Study Population
We identified 110,193 patients with histologically confirmed PCa (International Classification of Disease for Oncology [ICD-O] site code 61.9, histologic code 8140), aged 66 years or older, and diagnosed between 1999 and 2009.
This study focused exclusively on 6993 patients with metastatic PCa as their initial diagnosis who died between 1999 and 2009. We limited our population to 4759 patients with metastatic PCa enrolled in both Medicare Part A and Part B for the 12 months before death and were not members of a health maintenance organization. Additional exclusion criteria consisted of race other than white or black (n=384), disease that was diagnosed on autopsy or on death certificate only (n=2), unknown tumor stage (n=488), and unknown socioeconomic status (n=96). This yielded a total of 3789 assessable patients (supplemental eAppendix 1, available with this article at JNCCN.org).
Covariates
For each patient, age at death, year of PCa-specific mortality, race, population density, marital status, year of diagnosis, 2000 census tract percent with 4-year college education, 2000 census tract annual median income, and region were assigned.20 The Charlson comorbidity index (CCI) was derived from the Medicare claims 1 year before PCa diagnosis using a previously validated algorithm.21 Metropolitan areas were defined using the “Urban/Rural recode” field provided by SEER-Medicare database. Specifically, “Big Metro” and “Metro” areas were defined as metropolitan, whereas all the other areas were defined as nonmetropolitan.
End Points
We addressed 2 main end points. First, to address health care use within the last year of life, we ascertained diagnostic and treatment procedures performed during the last 12 months, 3 months, and 1 month of life by searching Medicare files using a previously described methodology.11 Specifically, we focused on the most common procedures performed: laboratory studies, prostate-specific antigen (PSA) testing, cystourethroscopy, Foley catheter placement, electrocardiography, imaging, hormonal therapy, chemotherapy, and any radiotherapy. Moreover, we evaluated outpatient office visits. Second, we evaluated the use of high-intensity care within the last year of life. As previously reported, high-intensity care was defined as more than 1 ED visit, any inpatient admission, ICU admission, cardiopulmonary resuscitation, and/or stent/nephrostomy tube placement2,3,11 (see supplemental eAppendix 2).
Statistical Analyses
Medians and interquartile ranges (IQRs) were reported for continuous variables. Frequencies and proportions were reported for categorical variables. The Mann-Whitney U test and chi-square tests were used to compare medians and proportions, respectively.
Our statistical analyses consisted of several steps. First, we examined the between-race variability in receipt of EOL care, including care visits and procedures. Second, we examined between-race variability in the receipt of high-intensity EOL care. Finally, multivariable logistic regression tested the relationship between race and the following end points: the receipt of diagnostic and therapeutic procedures, care visits, and receipt of high-intensity EOL care. The multivariable model was also used to calculate and plot the time-trend adjusted probability of receiving high-intensity EOL care. All of the aforementioned analyses were addressed at 3 time points: 12 months, 3 months, and 1 month before EOL (PSA mortality). Covariates consisted of age at death, CCI, educational attainment, median census tract income, marital status, year of diagnosis, geographic region, and metropolitan status.
All analyses were performed using SAS version 9.1.3 (SAS Institute Inc, Cary, NC). All tests were 2-sided, with a significance level set at a P value of less than .05. An Institutional Review Board waiver was obtained before the study was conducted, in accordance with institutional regulation when dealing with deidentified previously collected data.
Results
Overall, 378 of the accessible study patients from the SEER-Medicare database died of PCa between 1999 and 2009 (Table 1). Of these, 729 (19.24%) were black. The median patient age of the total population was 78.8 years (IQR, 73.1–84.4 years). Most patients had a CCI of 0 (73.8%), were married (58.9%), lived in the metropolitan area (79.8%), and originated from the West region (39.2%).
Compared with white men, black men were younger at death (median age, 76.6 vs 79.3 years; P<.001), had lower income (very low income: 58.9% vs 17.4%), had lower education (very low education: 52.5% vs 18.8%), were less frequently married (63.0% vs 41.8%), and lived more frequently in the metropolitan area (87.9% vs 77.9%). Most white patients originated from the West (42.9%), whereas most black patients (42.4%) originated from the South (all P<.0001). Other differences are reported in Table 1. Bivariate comparisons of health care use are summarized in Table 2. At 12 months before death, laboratory tests (89.2% vs 94.8%), PSA tests (68.3% vs 82.4%), cystourethroscopy (16.5% vs 21.2%), Foley catheter placement (12.2% vs 16.4%), imaging procedure (90.0% vs 93.9%), hormone therapy (50.9% vs 66.8%), chemotherapy (30.6% vs 44.3%), radiotherapy (32.7% vs 40.0%), and office visits (81.6% vs 92.7%) were less frequently used in black versus white men, respectively (all P≤.005). These reported observations were similar at 3 months and 1 month before death (Table 2) and on multivariable analyses, adjusting for age at death, CCI, educational attainment, median census tract income, marital status, year of diagnosis, geographic region, and metropolitan status (Table 3).
In the 12 months before death, high-intensity EOL care was more frequent in black versus white men (93.5% vs 90.2%; P=.004). Specifically, more than one ED visit, ICU admission, inpatient admission, and cardiopulmonary resuscitation were more frequent among black men versus white men (all P≤.003). These trends were confirmed at 3 months and 1 month before death (Table 2), and on multivariable analyses, adjusting for the same aforementioned covariates (Table 3).
Figure 1 depicts the trends in high-intensity EOL care among white and black patients over the duration of the study. Among white men, in the period between 1999 and 2000 and 2009, the prevalence of high-intensity EOL care decreased from 92.4% to 88.1% (P<.001), 75.6% to 70.2% (P<.001), and 50.9% to 44.5% (P<.001) at 12 months, 3 months, and 1 month, respectively, before death. Among black men, in the period between 1999 and 2000 and 2009, the prevalence of high-intensity care decreased from 94.8% to 91.8% (P<.001), 81.9% to 77.7% (P<.001), and 55.9% to 50.0% (P<.001) at 12 months, 3 months, and 1 month, respectively, before death.
Discussion
There is sufficient evidence from prior investigations to support the existence of racial disparities in care among patients dying of cancer. This subpopulation of patients with cancer is unique because it pits true quality of care considerations against sociodemographic and cultural perceptions of death. Regardless, none of the previous reports focused exclusively on patients with advanced PCa. Moreover, these studies have only investigated the indicators of aggressive/high-intensity EOL care and have not commented on the use of diagnostic and therapeutic interventions among black and white patients. To address this gap in knowledge, we examined the differences in diagnostic care, therapeutic interventions, and indicators of high-intensity EOL care among black and white patients in the last year of life.
Descriptive SEER-Medicare Database Statistics for Men Aged 66 Years or Older Who Died of Prostate Cancer (1999–2009)
Our study has several noteworthy findings. First, it highlights the stark contrast in EOL care among black patients compared with white patients. Specifically, black patients with end-stage PCa were more likely to have ICU and inpatient admissions, and were more likely to receive cardiopulmonary resuscitation. We therefore corroborate previous studies reporting concerning rates of high-intensity EOL care among black patients with end-stage cancers.8–12 For example, Smith et al10 in their study of advanced-stage lung, colorectal, breast, and prostate cancers showed that black patients were more likely to receive high-intensity care, specifically hospital admission (odds ratio [OR], 1.26; 95% CI, 1.14–1.41), duration of hospitalization (OR, 1.54; 95% CI, 1.39–1.71), ICU admission (OR, 1.15; 95% CI, 1.04–1.27), and in-hospital death (OR, 1.12; 95% CI, 1.11–1.32). Likewise, Earle et al12 found that black patients with lung, breast, and gastrointestinal malignancies were more likely to receive aggressive EOL treatment (OR, 1.25; 95% CI, 1.01–1.55), especially if treated in nonteaching hospitals. Finally, Loggers et al9 focused on a small, multisite, interview-based cohort, and observed that black patients with advanced cancers were 3 times more likely as white patients to receive high-intensity EOL care in terms of receipt of ventilation or cardiopulmonary resuscitation and deaths in the ICU.
Such aggressive treatments close to death may represent poor quality of care, because these treatments
Bivariate Comparison of Health Care Use in the Last Year of Life Among 3789 White and Black Men Aged ≥66 Years Within the SEER-Medicare Linked Database Who Died of Prostate Cancer Between 1999 and 2009
Multivariable Logistic Regression Analyses Evaluating the Effect of Black Race on End-of-Life Quality-of-Care Measures for Patients Dying of Prostate Cancer Within the SEER-Medicare Linked Database Between 1999 and 2009
The second noteworthy finding was that we observed that a significantly lower proportion of black patients had office visits compared with white patients. This finding may reflect lesser availability and access to primary health care facilities in black patients, which has been evaluated by several previous studies.24–27 Yasaitis et al27 used Medicare claims from 2006 to 2007, and data from national surveys of Medicare beneficiaries and primary care physicians, and observed that black patients had 2.14 fewer visits than other patients with similar health and preferences (point estimate, 2.14; 95% CI, −3.92 to −0.37). Using data from the household component of the 2010 Medical Expenditure Panel Survey,
Trends in high-intensity end-of-life care among 3789 patients with end-stage prostate cancer who died between 1999 and 2009 within the SEER-Medicare database. High-intensity care was defined as >1 emergency department visit, any inpatient admission, cardiopulmonary resuscitation, stent/nephrostomy placement, and intensive care unit admission within the last (A) 12 months, (B) 3 months, and (C) 1 month of life.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 13, 9; 10.6004/jnccn.2015.0138
Trends in high-intensity end-of-life care among 3789 patients with end-stage prostate cancer who died between 1999 and 2009 within the SEER-Medicare database. High-intensity care was defined as >1 emergency department visit, any inpatient admission, cardiopulmonary resuscitation, stent/nephrostomy placement, and intensive care unit admission within the last (A) 12 months, (B) 3 months, and (C) 1 month of life.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 13, 9; 10.6004/jnccn.2015.0138
Trends in high-intensity end-of-life care among 3789 patients with end-stage prostate cancer who died between 1999 and 2009 within the SEER-Medicare database. High-intensity care was defined as >1 emergency department visit, any inpatient admission, cardiopulmonary resuscitation, stent/nephrostomy placement, and intensive care unit admission within the last (A) 12 months, (B) 3 months, and (C) 1 month of life.
Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 13, 9; 10.6004/jnccn.2015.0138
Third, black patients are less likely to receive appropriate diagnostic and therapeutic interventions at EOL. Specifically, black patients dying of PCa were less likely to undergo diagnostic procedures, such as PSA testing, laboratory testing, and cystourethroscopy, in their last year, 3 months, or month of life. Moreover, at the same time points, these patients were also less likely to undergo therapeutic interventions, such as hormonal therapy, chemotherapy, or radiotherapy, and to have outpatient office visits. Although these aspects of EOL management are also important, they were poorly addressed in the literature, because prior studies, discussed earlier, have focused exclusively on the prevalence and disparities with respect to high-intensity care.
Fourth, the proportion of black and white patients receiving high-intensity EOL care has significantly decreased over the past 10 years. These trends are encouraging, although a greater proportion of terminally ill black patients continue to receive high-intensity EOL care relative to their white counterparts. Our findings contrast with those of Earle et al,12 who showed that the overall prevalence of high-intensity EOL care was increasing between 1993 and 1996. However, Han et al,28 in their study spanning 1992 through 2000, reported a 4-fold increase in hospice use among black patients and a 2-fold increase among white patients, which probably explains the decrease in aggressive EOL care observed between 1999 and 2009 in the current study. Teno et al29 tracked the changes in EOL care among Medicare beneficiaries and observed a decrease in the proportion of patients dying in acute care hospitals (32.6% vs 24.6%; 2000 vs 2009) and an increase in hospice use (21.6% vs 42.2%; 2000 vs 2009). Intriguingly, although the prevalence of high-intensity EOL care during the last month of life among white men began to decrease as early as the year from 2001 to 2002, a similar trend was not observed in black men until the year from 2005 to 2006. The reason for this disparity is unclear, but this further highlights the compromised quality of care in the black population. Possible explanations include resistance to use of palliative care and hospice care among black patients,11,12 driven by patient and family preferences,30,31 a lack of proper physician-patient communication,16 or the lack of awareness about EOL options and outcomes.32,33
Despite the strengths of our study, it is not devoid of limitations. First, this is a retrospective observational study and, although we identified a cohort of patients dying of PCa, we cannot ascertain whether our results reflect physician attitudes, access to care, and/or cultural beliefs. Second, there are potentially many unmeasured confounders, such as patient preferences and clinician awareness, which may have impacted the differences noted in the receipt of diagnostic care, therapeutic interventions, and EOL care. Moreover, we excluded Hispanic patients to focus on the disparities among non-Hispanic black and white patients. Furthermore, there are limitations to using the SEER-Medicare database that was used in this study. The coverage of SEER-Medicare data is limited to 26% of the total US population and to patients aged 65 years or older. Use of chemotherapy and androgen deprivation therapy is underreported and not available in the public use files, although it can be ascertained from billing claims.
Conclusions
Our study highlights the existence of significant racial disparities in EOL care; broadly speaking, black patients are less likely to undergo therapeutic and diagnostic interventions, and are more likely to receive high-intensity EOL care. Our trend analysis shows that the prevalence of high-intensity EOL care has decreased over the past decade, but at a more significant rate for white versus black patients. Further research is needed to understand the causes for these disparities and to design interventions to address these disparities.
Dr. Abdollah is a consultant for GenomeDx biosciences. Dr. Nguyen is a consultant for Ferring and Medivation. Dr. Kibel is a consult for Sanofi-Aventis, Dendreon, and Myriad. Dr. Trinh is supported by the Professor Walter Morris-Hale Distinguished Chair in Urologic Oncology at the Brigham and Women's Hospital. The remaining authors have disclosed that they have no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors.
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