outline_expanded.htm

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*
Cancer Death Rates* by Sex, US, 1975-2004
Cancer Death Rates* Among Men, US,1930-2004
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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
Comparison: White vs. AA
Comparison: White vs. AA
Comparison: White vs. AA
Comparison: White vs. AA
Comparison: White vs. AA
Specific Aim 1
Compare mortality rates between African-Americans and Caucasians with newly diagnosed prostate cancer in Los Angeles County

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Specific Aim 2
Compare the mortality rates for prostate cancer between NCI-designated Cancer Centers and other treatment facilities in Los Angeles County

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

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Multivariate analysis
Overall mortality: AA vs. White
Prostate-specific mortality: AA vs. White
Multivariate analysis
Overall mortality: NCI vs. non-NCI
 Prostate-specific mortality: NCI vs. non-NCI
Multivariate 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

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Utilization of NCI Cancer Centers: AA vs. White
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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,

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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

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

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