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
- ↑ Australian Institute of Health and Welfare. Australia's Health 2008. AIHW 2008 Jan 1 Available from: http://www.fairfieldcity.nsw.gov.au/upload/kdtyt23699/AustraliaHealth08.pdf.
- ↑ 2.0 2.1 NSW Central Cancer Registry. NSW Central Cancer Registry Reporting Module. NSW Central Cancer Registry 2007 May 2 Available from: http://www.statistics.cancerinstitute.org.au/.
- ↑ 3.0 3.1 Hall SE, Holman CD, Wisniewski ZS, Semmens J. Prostate cancer: socio-economic, geographical and private-health insurance effects on care and survival. BJU Int 2005 Jan;95(1):51-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15638894.
- ↑ Desch CE, Penberthy L, Newschaffer CJ, Hillner BE, Whittemore M, McClish D, et al. Factors that determine the treatment for local and regional prostate cancer. Med Care 1996 Feb;34(2):152-62 Available from: http://www.ncbi.nlm.nih.gov/pubmed/8632689.
- ↑ Polednak AP. Prostate cancer treatment in black and white men: the need to consider both stage at diagnosis and socioeconomic status. J Natl Med Assoc 1998 Feb;90(2):101-4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9510624.
- ↑ Krupski TL, Kwan L, Afifi AA, Litwin MS. Geographic and socioeconomic variation in the treatment of prostate cancer. J Clin Oncol 2005 Nov 1;23(31):7881-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16204005.
- ↑ Sadetsky N, Lubeck DP, Pasta DJ, Latini DM, DuChane J, Carroll PR. Insurance and quality of life in men with prostate cancer: data from the Cancer of the Prostate Strategic Urological Research Endeavor. BJU Int 2008 Mar;101(6):691-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18291018.
- ↑ Miller DC, Litwin MS, Bergman J, Stepanian S, Connor SE, Kwan L, et al. Prostate cancer severity among low income, uninsured men. J Urol 2009 Feb;181(2):579-83; discussion 583-4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19100580.
- ↑ Du XL, Fang S, Coker AL, Sanderson M, Aragaki C, Cormier JN, et al. Racial disparity and socioeconomic status in association with survival in older men with local/regional stage prostate carcinoma: findings from a large community-based cohort. Cancer 2006 Mar 15;106(6):1276-85 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16475208.
- ↑ Coory MD, Baade PD. Urban-rural differences in prostate cancer mortality, radical prostatectomy and prostate-specific antigen testing in Australia. Med J Aust 2005 Feb 7;182(3):112-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15698354.
- ↑ Jong KE, Smith DP, Yu XQ, O'Connell DL, Goldstein D, Armstrong BK. Remoteness of residence and survival from cancer in New South Wales. Med J Aust 2004 Jun 21;180(12):618-22 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15200358.
- ↑ Hayen A, Smith DP, Patel MI, O'Connell DL. Patterns of surgical care for prostate cancer in NSW, 1993-2002: rural/urban and socio-economic variation. Aust N Z J Public Health 2008 Oct;32(5):417-20 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18959543.
- ↑ Condon JR, Armstrong BK, Barnes A, Cunningham J. Cancer in Indigenous Australians: a review. Cancer Causes Control 2003 Mar;14(2):109-21 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12749716.
- ↑ Condon JR, Barnes T, Cunningham J, Armstrong BK. Long-term trends in cancer mortality for Indigenous Australians in the Northern Territory. Med J Aust 2004 May 17;180(10):504-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15139826.
- ↑ Powell IJ, Banerjee M, Novallo M, Sakr W, Grignon D, Wood DP, et al. Prostate cancer biochemical recurrence stage for stage is more frequent among African-American than white men with locally advanced but not organ-confined disease. Urology 2000 Feb;55(2):246-51 Available from: http://www.ncbi.nlm.nih.gov/pubmed/10688088.
- ↑ Thompson I, Tangen C, Tolcher A, Crawford E, Eisenberger M, Moinpour C. Association of African-American ethnic background with survival in men with metastatic prostate cancer. J Natl Cancer Inst 2001 Feb 7;93(3):219-25 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11158191.
- ↑ Evans S, Metcalfe C, Ibrahim F, Persad R, Ben-Shlomo Y. Investigating Black-White differences in prostate cancer prognosis: A systematic review and meta-analysis. Int J Cancer 2008 Jul 15;123(2):430-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18452170.
- ↑ Halabi S, Small EJ, Vogelzang NJ, Barrier RC Jr, George SL, Gilligan TD. Impact of race on survival in men with metastatic hormone-refractory prostate cancer. Urology 2004 Aug;64(2):212-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15302462.
- ↑ Tewari A, Horninger W, Pelzer AE, Demers R, Crawford ED, Gamito EJ, et al. Factors contributing to the racial differences in prostate cancer mortality. BJU Int 2005 Dec;96(9):1247-52 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16287439.
- ↑ Robbins AS, Yin D, Parikh-Patel A. Differences in prognostic factors and survival among White men and Black men with prostate cancer, California, 1995-2004. Am J Epidemiol 2007 Jul 1;166(1):71-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17426038.
- ↑ Gilligan T. Social disparities and prostate cancer: mapping the gaps in our knowledge. Cancer Causes Control 2005 Feb;16(1):45-53 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15750857.
- ↑ Supramaniam R, O'Connell DL, Tracey EA, Sitas F. Cancer Incidence in New South Wales Migrants 1991 to 2001. Cancer Council NSW 2006 Jan 1 Available from: http://svc013.wic047p.server-web.com/html/research/epidemiological/downloads/cancer_in_migrants.pdf.
- ↑ Holden CA, Jolley DJ, McLachlan RI, Pitts M, Cumming R, Wittert G, et al. Men in Australia Telephone Survey (MATeS): predictors of men's help-seeking behaviour for reproductive health disorders. Med J Aust 2006 Oct 16;185(8):418-22 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17137429.
- ↑ Weber MF, Banks E, Smith DP, O'Connell D, Sitas F. Cancer screening among migrants in an Australian cohort; cross-sectional analyses from the 45 and Up Study. BMC Public Health 2009 May 15;9:144 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19442312.
- ↑ Knight SJ, Chmiel JS, Kuzel T, Sharp L, Albers M, Fine R, et al. Quality of life in metastatic prostate cancer among men of lower socioeconomic status: feasibility and criterion related validity of 3 measures. J Urol 1998 Nov;160(5):1765-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9783948.
- ↑ Bennett CL, Ferreira MR, Davis TC, Kaplan J, Weinberger M, Kuzel T, et al. Relation between literacy, race, and stage of presentation among low-income patients with prostate cancer. J Clin Oncol 1998 Sep;16(9):3101-4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/9738581.
- ↑ Rayford W. Managing the low-socioeconomic-status prostate cancer patient. J Natl Med Assoc 2006 Apr;98(4):521-30 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16623064.
- ↑ Gaston CM, Mitchell G. Information giving and decision-making in patients with advanced cancer: a systematic review. Soc Sci Med 2005 Nov;61(10):2252-64 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15922501.
- ↑ Konski A, Desilvio M, Hartsell W, Watkins-Bruner D, Coyne J, Scarantino C, et al. Continuing evidence for poorer treatment outcomes for single male patients: retreatment data from RTOG 97-14. Int J Radiat Oncol Biol Phys 2006 Sep 1;66(1):229-33 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16814950.
- ↑ Smith DP, Supramaniam R, King MT, Ward J, Berry M, Armstrong BK. Age, health, and education determine supportive care needs of men younger than 70 years with prostate cancer. J Clin Oncol 2007 Jun 20;25(18):2560-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17577034.
- ↑ Steginga SK, Occhipinti S, Dunn J, Gardiner RA, Heathcote P, Yaxley J. The supportive care needs of men with prostate cancer (2000). Psychooncology 2001;10(1):66-75 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11180578.
- ↑ National Health and Medical Research Council. Using socioeconomic evidence in clinical practice guidelines. NHMRC 2002 Available from: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cp89.pdf.
- ↑ Nijs HG, Essink-Bot ML, DeKoning HJ, Kirkels WJ, Schröder FH. Why do men refuse or attend population-based screening for prostate cancer? J Public Health Med 2000 Sep;22(3):312-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11077903.
- ↑ Mills N, Metcalfe C, Ronsmans C, Davis M, Lane JA, Sterne JA, et al. A comparison of socio-demographic and psychological factors between patients consenting to randomisation and those selecting treatment (the ProtecT study). Contemp Clin Trials 2006 Oct;27(5):413-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/16774847.
- ↑ Lamerato LE, Marcus PM, Jacobsen G, Johnson CC. Recruitment in the prostate, lung, colorectal, and ovarian (PLCO) cancer screening trial: the first phase of recruitment at Henry Ford Health System. Cancer Epidemiol Biomarkers Prev 2008 Apr;17(4):827-33 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18398023.
- ↑ Pinsky PF, Ford M, Gamito E, Higgins D, Jenkins V, Lamerato L, et al. Enrollment of racial and ethnic minorities in the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial. J Natl Med Assoc 2008 Mar;100(3):291-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18390022.
- ↑ Moinpour CM, Lovato LC, Thompson IM Jr, Ware JE Jr, Ganz PA, Patrick DL, et al. Profile of men randomized to the prostate cancer prevention trial: baseline health-related quality of life, urinary and sexual functioning, and health behaviors. J Clin Oncol 2000 May;18(9):1942-53 Available from: http://www.ncbi.nlm.nih.gov/pubmed/10784636.