1. 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

2. 2008 Estimated US Cancer Deaths* ONS=Other nervous system. Source: American Cancer Society, 2008. Men 294,120 Lung & bronchus31% Prostate10% Colon & rectum8% Pancreas6% Liver & intrahepatic bile duct4% Leukemia4% Esophagus 4% Urinary bladder3% Non-Hodgkin lymphoma3% Kidney & renal pelvis3% All other sites24%

3. 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). Men Both Sexes Rate Per 100,000 Women

4. 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. Rate Per 100,000 Prostate

5. Prostate Cancer Mortality Rates in the US, 1969-2004

6. 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, 2005 Per 100,000 population White, Non-Hispanic Hispanic African American, Non-Hispanic Asian and Pacific Islander American Indian/Alaska Native Deaths

7. 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

8. 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

9. 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

10. 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

11. 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)

12. 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

13. Comparison: White vs. AA White N=14, 579 AA N=4211 Alive 11856 (81%)3328 (79%) Dead 2723 (19%)883 (21%)* prostate-specific543 (4%)200 (5%)* other2180 (15%)683 (16%)* *P <0.05

14. Comparison: White vs. AA WhiteAA Age at Dx 68 (16-99)64 (33-93)* Stage Local12831 (88.0%)3708 (88.1%) Regional1290 (8.9%))286 (6.8%)* Distant458 (3.1%)217 (5.1%)* Grade Well-differentiated525 (3.6%)151 (3.6%) Moderately differentiated10932 (75.0%)3177 (75.4%) Poor/undifferentiated3122 (21.4%)883 (21.0%) *P<0.05

15. Comparison: White vs. AA WhiteAA Treatment Watchful waiting2284 (15.7%)925 (20.0%)* Surgery only5419 (37.2%)1420 (33.7%)* Hormone only1759 (12.1%)561 (13.3%) Radiation only2371 (16.2%)691 (16.4%) Combination of Surgery /hormone /radiation 2746 (18.8%)614 (14.6%)* *P<0.05

16. Comparison: White vs. AA WhiteAA SES 1 (highest)6499 (44.6%)568 (13.5%)* 23667 (25.1%)719 (17.1%)* 32464 (16.9%)897 (21.3%)* 41383 (9.5%)1072 (25.4%)* 5 (lowest)566 (3.9%)955 (22.7%)* *P<0.05

17. Comparison: White vs. AA WhiteAA Insurance no211 (1.5%)195 (4.6%)* Insurance NOS806 (5.5%)144 (3.4%)* Managed care, HMO PPO7977 (54.7%)2329 (55.3%) Medicare2781 (19.1%)439 (10.4%)* Military, Veterinarian, PHS290 (2.0%)251 (6.0%)* County funded2514 (17.2%)853 (20.3%)*

18. Specific Aim 1 Compare mortality rates between African-Americans and Caucasians with newly diagnosed prostate cancer in Los Angeles County

19. Overall Mortality P<0.001 Prostate-specific P=0.002

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

21. Prostate-specific P<0.001 Overall mortality P<0.001

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

23. Prostate-specific P=0.52 Overall Mortality P=0.17

24. 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.

25. Overall mortality: AA vs. White

26. Prostate-specific mortality: AA vs. White

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

28. Overall mortality: NCI vs. non-NCI

29. Prostate-specific mortality: NCI vs. non-NCI

30. 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.

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

32. Non-NCINCIOR Race White12933 (88.7%)1646 (11.3%)1.00 AA4063 (96.5%)148 (3.5%)0.29 (0.24-0.34) Utilization of NCI-designated Cancer Center

33. Utilization of NCI Cancer Centers: AA vs. White

34. Utilization of NCI-designated Cancer Center OR (95% CI) AA vs. White0.42 (0.35-0.50) Age at diagnosis (years)0.95 (0.94-0.95) SES =1 highest SES =20.61 (0.53-0.69) SES =30.41 (0.35-0.49) SES =40.37 (0.30-0.46) SES =5 lowest0.30 (0.22-0.42) Insurance: no1.00 Insurance NOS2.55 (1.58-4.12) Managed care HMO PPO1.05 (0.67-1.66) Medicare3.22 (2.01-5.13) County0.08 (0.02-0.34) Military/veteran/ PHS2.12 (1.32-3.40)

35. Utilization of NCI-designated Cancer Center OR (95% CI) Grade: well-differentiated1.00 Moderately differentiated3.11 (1.87-5.18) Poor/undifferentiated3.79 (2.25-6.36) Stage: localized1.00 Regional1.29 (1.10-1.51) Distant1.12 (0.75-1.65) Treatment: watchful waiting1.00 Surgery only2.65 (2.16-3.25) Hormone only0.80 (0.59-1.09) Radiation only1.04 (0.81-1.33) Multiple1.36 (1.09-1.70) Year of Dx (more recent years)1.06 (1.03-1.10)

36. 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

37. 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,

39. Thank you!

40. 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.

41. 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

42. 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.

43. Overall HRProstate-specific HR AA vs. White1.08 (0.99-1.17)1.12 (0.93-1.35) NCI center vs. non-NCI0.75 (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 highest1.00 SES =21.21 (1.10-1.33)1.08 (0.87-1.33) SES =31.33 (1.21-1.47)1.26 (1.02-1.55) SES =41.37 (1.23-1.52)1.15 (0.91-1.46) SES =5 lowest1.46 (1.29-1.66)1.29 (0.99-1.68) No Insurance:1.00 Insurance NOS0.53 (0.39-0.71)0.46 (0.25-0.84) HMO PPO0.84 (0.67-1.05)0.91 (0.60-1.39) Medicare0.86 (0.68-1.08)0.82 (0.53-1.28) Military/Vet/ Indian/PHS0.80 (0.61-1.06)0.70 (0.40-1.22) County funded0.82 (0.65-1.03)0.74 (0.48-1.15)

44. Overall HRProstate-specific HR Grade: well-differentiated1.00 Moderately differentiated1.08 (0.91-1.28)1.68 (0.91-3.07) Poor/undifferentiated1.69 (1.42-2.01)4.87 (2.66-8.92) Stage: localized1.00 Regional1.25 (1.07-1.38)2.28 (1.76-2.94) Distant3.76 (3.38-4.18)14.72 (12.21-17.76) Treatment: watchful waiting1.00 Surgery only0.31 (0.28-0.35)0.19 (0.13-0.27) Hormone only1.04 (0.95-1.15)1.29 (1.05-1.60) Radiation only0.61 (0.55-0.68)0.50 (0.36-0.70) Multiple0.67 (0.60-0.74)0.86 (0.67-1.09) Year of Dx1.03 (1.01-1.06)0.98 (0.93-1.03)