Socio-economic aspects of advanced prostate cancer
Socio-economic aspects of advanced prostate cancer
Adverse social and economic circumstances are well-recognised determinants of access to and use of health care. Less affluent or socially disadvantaged people live shorter lives and suffer more illness than those who are well off.Guideline development needs to consider how issues such as income, education, occupation or employment, ethnicity, indigenous status, literacy, and place of residence affect risk factors, use of health care services and outcomes of care. There is growing evidence that socio-economic status (SES) is associated with prostate cancer outcomes, particularly participation in PSA testing, patterns of care for localised disease and with survival and mortality outcomes. Most of this evidence is based on American or European studies. Randomised controlled trials rarely report whether trial selection is associated with social class or whether interventions for advanced prostate cancer are confounded by SES. The relationships between SES and prostate cancer incidence, mortality and survival in Australia are poorly understood and even less is known about the association between SES and advanced prostate cancer.
A number of studies have demonstrated a higher risk of diagnosis of prostate cancer in men from higher SES groups. This is likely to be related to higher prevalence of prostate cancer testing in those with higher education, income and health-seeking behaviours. In New South Wales between 2002 and 2006, the incidence of prostate cancer was 15% higher than average in men resident in the highest socio-economic status areas, compared to an 8% lower risk in the lowest SES group. However there was no significant difference in mortality rates by SES groups. Hall, using linked administrative data from Western Australia, found higher three-year mortality from prostate cancer in more socioeconomically disadvantaged groups (relative risk=1.34, 95% CI=1.10 to 1.64), whereas those admitted to a private hospital (relative risk=0.77, 95% CI=0.71 to 0.84) or with private health insurance (relative risk=0.82, 95% CI=0.76 to 0.89) fared better. International studies have shown that men with localised disease with lower incomes are less likely to be treated at all, and if treated for localised cancer they are less likely to have prostatectomy and more likely to have radiation therapy.A number of studies have shown that men with higher incomes and private health insurance status are more likely to have aggressive treatment, better quality of life and lower mortality from prostate cancer. The role of income, education and health insurance in the determination of advanced prostate cancer outcomes in Australia has never been explored.
Coory and Baade10, using administrative data for the whole of Australia, found a statistically significant and increasing excess risk for prostate cancer mortality in regional and rural areas. In 2000–2002, the excess (compared with capital cities) was 21% (95% CI=14% to 29%). The authors suggested that this was likely related to lower rates of screening with PSA tests and treatment with radical prostatectomy in rural and regional Australia.Western Australia data indicate that the three-year mortality rate for prostate cancer was greater with a first admission to a rural hospital (relative risk=1.22, 95% CI=1.09 to 1.36) compared to non-rural hospitals. A survival analysis comparing rural and remote residents of NSW found a more than three-fold relative excess risk of death by five years in men from rural and remote NSW (relative risk=3.38, 95% CI=2.21 to 5.16). This was partly driven by later stage of disease at diagnosis in men from rural and remote areas. An analysis of linked data for NSW for the period 1993–2002 also showed associations between SES and rural/urban areas of residence and the type of treatment received. Prostate cancer patients from less accessible areas of the state were more likely to have orchidectomy than those from accessible areas and men from more socially disadvantaged areas also had higher rates of orchidectomy.The most recent data continue to show the incidence gradient in risk of all prostate cancer by rural and urban status but indicate that the inequity in mortality may have declined. Data from the NSW Central Cancer Registry show that men in rural areas had 28% (95% CI=9% to 49%) higher than expected incidence of prostate cancer but no significant difference in mortality.
Indigenous Australians have lower risk of diagnosis of prostate cancer compared to non-indigenous Australians.The prostate cancer mortality rate ratio for indigenous males from the Northern Territory was 0.4 (95% CI=0.2 to 0.8), indicating lower risk of death from prostate cancer in indigenous Australians.
Ethnicity and race
Black men have the highest incidence and mortality rates from prostate cancer worldwide. In a systematic review of 29 studies in the USA, 79% observed no difference in treatment outcomes in black men after controlling for tumour and patient characteristics. Although several studies have focussed on outcomes in men with locally advanced or metastatic prostate cancer and showed worse outcomes in black men, other studies of metastatic cancer did not find evidence of black–white differences in all cause or prostate cancer survival. In a study of 1183 men with hormone-refractory prostate cancer from eight multicentre trials, race had no effect on the median survival time of blacks compared with whites (hazard ratio 0.85, 95% CI=0.71 to 1.02, p=0.08). Observational studies have demonstrated that much of the racial difference in survival from prostate cancer is confounded by black men’s younger age at diagnosis, more distant stage, higher tumour grades, less aggressive treatment and lower SES while others dispute whether race is associated with survival per se. Australian men born in other countries generally have lower risk of developing prostate cancer and of dying from it than Australian-born males, but higher risk of developing prostate cancer than reported in their native countries. Whether ethnic differences in men’s willingness to access screening and treatment for prostate cancer in Australia follows through into differences in treatment for men with advanced prostate cancer is unknown.
Literacy and language ability
Poor literacy in USA populations is associated with advanced-stage prostate cancer and has been linked to increased prostate cancer mortality. Low literacy levels likely result in complex interactions in the communications between care givers and patients regarding compliance with treatment, treatment outcomes and the decision-making process. A systematic review of decision making in patients with advanced cancer showed active decision making was less common in men with prostate cancer than in women with breast cancer. A number of simple interventions including question prompt sheets, audio-taping of consultations and patient decision aids have been shown to facilitate increased involvement in decision making.
An RCT in the USA of men with metastatic prostate cancer indicated that a lack of social support for single males potentially led to earlier re-treatment rates and concluded this was partly due to inadequate social support in receiving additional care. Two Australian surveys of the supportive care needs of men with prostate cancer (irrespective of stage) have shown higher levels of unmet needs in men with lower income or lower levels of education.
Socio-economic status and involvement in randomised controlled trials
Participants in randomised controlled trials, the source of the evidence predominantly used to inform the recommendations in these guidelines, may not fully represent economically or socially disadvantaged sub-populations because of lower participation by these groups in trials.Whether this affects the ability to generalise the results from these trials is seldom reported. Several of the larger population-wide randomised controlled trials of prostate cancer screening and treatment have identified socio-economic differences in race, income and occupation between participants and nonparticipants.  Similarly, men with chronic disabilities are significantly less likely to participate in prostate cancer prevention trials.
Socio-economic status implications for these guidelines
Understanding the precise role of SES in relation to advanced prostate cancer outcomes is a key challenge for future research. There is a lack of clear evidence from either international studies or local surveys of advanced prostate cancer patients to indicate that inequity in outcomes is associated with social or economic resources of patients. However, by extending the evidence from studies of access to care for localised prostate cancer, it would appear that certain groups may be at risk of inequitable care, including socially or regionally isolated men and those without the means or education to find and purchase the best level of care.
Evidence summary and recommendations
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