Factors Associated with Time-to-Treatment of Prostate Cancer in Florida

Prostate cancer is the most commonly diagnosed cancer after skin cancer and the second leading cause of cancer death for American men, behind only lung cancer.¹ The American cancer society estimates that there will be about 238,590 new cases of prostate cancer, and 29,720 men will die from the disease in 2013.¹

Prostate cancer mortality rate is declining in developed countries, however it is not clear whether this is due to the increasing use of screening procedures based on prostate-specific antigen (PSA) blood test, improved treatment,² or combination of these and/or other factors.³ In spite of declining prostate cancer mortality, striking racial disparities in prostate cancer outcomes exist in the U.S. Compared with Caucasian men, African American are more likely to be diagnosed at advanced stage disease and die from prostate cancer in the U.S.^1,4

Studies have shown differences in prostate cancer treatment among patients with various races/ethnicities or socioeconomic backgrounds.^5–8 Existing literature suggests that African American men have not been receiving optimal treatment for prostate cancer and have been experiencing delays in treatment.^9–11 Such differences in treatment must be understood better and explained as they might be one cause of the racial disparities in prostate cancer mortality observed in the U.S. This information is critical for the development of appropriate policy and intervention strategies to eliminate long-term racial/ethnic disparities.

Several factors have been suggested to influence time-to-treatment in cancer patients, including socioeconomic status and other demographic characteristics.^12–15 In breast cancer, for instance, studies have shown that time-to-treatment may be linked to socioeconomic status as well as race. The same studies suggested that delays of greater than three months after an initial diagnosis may decrease breast cancer survival by 12%.^13–16

Some studies found that men with prostate cancer experience longer wait time for diagnosis and treatment than those observed for other cancers.^17–19 Studies in both the urologic and medical literature have paid increasing attention to the question of overdiagnosis in prostate cancer. As evidence, a study reported overdiagnosis rates of 15% among White men and 37% among Black men.²⁰ The association between wait time and prognosis of prostate cancer is inconclusive.^21–26 Even though we recognize the current literature’s debate on whether or not prostate cancer has been over-treated, the intent of this project was not to make a clinical judgment about this matter. This study intended to investigate factors contributing to time-to-treatment and examine whether there was a difference in wait time or treatment rate between African American and Caucasian men in Florida.

Methods

Population studied

Caucasian and African American men 40 years of age or older diagnosed with prostate cancer between Oct. 2001 and Dec. 2007 in Florida. Other races were excluded due to small numbers in the dataset.

Data sources

The study used data from three sources. First, prostate cancer incidence data between Oct. 2001-Dec. 2007 were obtained from the Florida Cancer Data System (FCDS) that is managed by State of Florida Department of Health and housed at the University of Miami through a contract. The FCDS is the largest population-based, cancer incidence registry in the nation.²⁷ It contains information on patient demographic characteristics, residence, prostate tumor characteristics, and other information such as tobacco use and primary payer of health insurance.

Second, comorbidity data were obtained from the Florida Agency for Health Care and Administration (AHCA). The AHCA maintains two databases (Hospital Patient Discharge Data and Ambulatory Outpatient Data) on all patient encounters within hospitals and freestanding ambulatory surgical and radiation therapy centers in Florida. Comorbidity was computed following the Elixhauser Index method²⁸ based on diagnoses information from AHCA. The study used a total of 45 conditions, including 29 from the Elixhauser Index plus 16 new additional conditions based on...