Access to definitive treatment and survival for intermediate-risk and high-risk prostate cancer at hospital systems serving health disparity populations
Muhieddine Labban, MD1, David-Dan Nguyen, MD1, Logan Briggs, MD1, Alexander P. Cole, MD1, Stuart R. Lipsitz, ScD1, Hari S. Iyer, ScD2, Timothy R. Rebbeck, PhD2, Joel S. Weissman, PhD1, Toni K. Choueiri, MD2, Quoc-Dien Trinh, MD1.
1Brigham and Women's Hospital, BOSTON, MA, USA, 2Dana-Farber Cancer Institute, BOSTON, MA, USA.
Background: Socioeconomic and racial disparities in prostate cancer (PCa) can be attributed to patient-level and physician-level factors. However, there is growing interest in investigating the role of the facility of care in driving cancer disparities. Therefore, we sought to examine the receipt of guideline-concordant definitive treatment, time to treatment initiation (TTI), and survival for men with PCa receiving care at hospital systems serving health disparity populations (HSDPs).
Methods: We conducted a retrospective analysis of the National Cancer Database (2004-2016) among men with intermediate-risk or high-risk PCa eligible for definitive treatment. The primary outcomes were receipt of definitive treatment and TTI within 90 days of diagnosis. The secondary outcome was survival. We defined HSDPs as minority-serving hospitals - facilities in the highest decile of proportion of Non-Hispanic Black (NHB) or Hispanic cancer patients - and/or high-burden safety-net hospitals - facilities in the highest quartile of proportion of underinsured patients. We used mixed-effect models with facility-level random intercept to compare outcomes between HSDPs and non-HSDPs among the entire cohort and among men who received definitive treatment. We evaluated interactions between HSDP status and race for each of the outcomes.
Results: The cohort included 821,931 men with intermediate-risk or high-risk PCa. We included 968 non-HSDPs (72.2%) and 373 HSDPs (27.8%) facilities. Treatment at HSDPs was associated with lower odds of receipt of definitive treatment (aOR 0.64; 95% CI 0.57-0.71; p < 0.001), lower odds of TTI within 90 days of diagnosis (aOR 0.74; 95% CI 0.68-0.79; p < 0.001), and worse survival (aHR 1.05; 95% CI 1.02-1.09; p = 0.003). However, no difference was found in survival among patients who received definitive treatment (p = 0.1). NHB men at HSDPs had also worse outcomes than NHB men treated at non-HSDPs as well as NHW men treated at HSDPs (Table 1).
Conclusion: Patients treated at HSDPs were less likely to receive timely definitive treatment and had worse survival. NHB men have worse outcomes than NHW at HSDPs. NHB men with PCa remain largely disadvantaged since they are more likely to be treated at hospitals with worse outcomes and have worse outcomes than other patients at those same institutions.
| Table 1: Interaction between race (NHW, n=634,917 and NHB, n=119,166) and patient treated at non-HSDP (n=603,346) versus HSDP facilities (n=150,737) | ||||||||
| Definitive Treatment | TTI within 90 days | Survival | Survival among men who received definitive treatment | |||||
| OR (95%CI) | p-value | OR (95%CI) | p-value | OR (95%CI) | p-value | OR (95%CI) | p-value | |
| NHB at HSDP vs. NHW at HSDP | 0.68 (0.66-0.71) | < 0.001 | 0.74 (0.72-0.76) | < 0.001 | 1.17 (1.12-1.23) | < 0.001 | 1.13 (1.07-1.19) | < 0.001 |
| NHB at HSDP vs. NHB at non-HSDP | 0.65 (0.58-0.73) | < 0.001 | 0.76 (0.70-0.82) | < 0.001 | 1.07 (1.00-1.14) | 0.05 | 1.04 (0.97-1.12) | 0.22 |
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