Temporal Trends and the Impact of Race, Insurance, and Socioeconomic Status in the Management of Localized Prostate Cancer

Eur Urol. 2017 May;71(5):729-737. doi: 10.1016/j.eururo.2016.08.047. Epub 2016 Sep 3.

Abstract

Background: Numerous management options exist for patients with prostate cancer; however, recent trends and their influencing factors are not well described.

Objective: To describe modern patterns of care and factors associated with management choice using the National Cancer Database.

Design, setting, and participants: Patients with localized prostate cancer diagnosed between 2004 and 2012 were included and grouped according to National Comprehensive Cancer Network guidelines into low, intermediate, or high risk.

Outcome measurements and statistical analysis: Trend analyses and multivariate logistic regression was used to identify factors associated with management.

Results and limitations: There were 598 640 patients who met the study criteria; 36.3% were classified as low risk, 43.8% intermediate risk, and 20.0% high risk. Over the study period, among low-risk patients, observation increased from 9.2% to 21.3%, while radical prostatectomy (RP) increased from 29.5% to 51.1% (p<0.001 for both). In contrast, external beam radiotherapy decreased from 24.3% to 14.5%, while brachytherapy decreased from 31.7% to 11.1%. A similar pattern was seen for patients with intermediate-risk or high-risk disease. Among high-risk patients, RP increased from 25.1% to 43.4% replacing external beam radiotherapy as the dominant therapy. On multivariate analysis, racial minorities, the uninsured, and low-income patients were less likely to receive RP. Low-risk patients in similar subgroups were significantly more likely to be observed. Limitations include potential miscoding or misclassification of variables.

Conclusions: Patterns of care in localized prostate cancer are changing rapidly. While use of observation is increasing in low-risk groups, the use of RP is increasing across all risk groups with a concomitant decline in use of radiotherapy. Socioeconomic factors appear to influence management choice.

Patient summary: In this report we identify a recent significant increase in the use of radical prostatectomy for prostate cancer patients. Socioeconomic factors such as race, insurance type, and income may affect treatments offered to and received by patients.

Keywords: Androgen deprivation therapy; Localized; Practice patterns; Prostate cancer.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • African Americans
  • Aged
  • Brachytherapy
  • Databases, Factual
  • Disease Management
  • Ethnic Groups / statistics & numerical data*
  • European Continental Ancestry Group
  • Healthcare Disparities / ethnology*
  • Healthcare Disparities / statistics & numerical data
  • Hispanic Americans
  • Humans
  • Insurance Coverage
  • Insurance, Health / statistics & numerical data*
  • Logistic Models
  • Male
  • Medicaid
  • Medically Uninsured
  • Medicare
  • Middle Aged
  • Minority Groups / statistics & numerical data
  • Multivariate Analysis
  • Prostatectomy*
  • Prostatic Neoplasms / therapy*
  • Radiotherapy*
  • Social Class*
  • United States
  • Watchful Waiting*