Researchers hypothesized that during a time of resource scarcity, the incidence of PSA-detected prostate cancer would decrease and the use of noncurative management strategies would increase, reports Urology Times SUO internship program member Ryan Hutchinson, MD.
|Ryan Hutchinson, MD||UT SUO 2015 Internship Program Member Profile|
Washington-Economic conditions and insurance status appear to predict prostate cancer diagnosis and management, according to a study presented at the 2015 Society of Urologic Oncology annual meeting in Washington.
The effect of the economic downturn of 2007-2009 on daily life was profound for many Americans. Less is known about how it affected the diagnosis and management of urologic cancers. Weiner et al from the University of Chicago hypothesized that during a time of resource scarcity such as the “great recession” from December 2007 to January 2009, the incidence of PSA-detected prostate cancer (cT1c) would decrease and the use of noncurative management strategies (such as active surveillance) would increase.
Using the Surveillance, Epidemiology, and End Results (SEER) cancer database, the authors compared macroeconomic factors such as per capita income, Standard and Poor (S&P 500) Index closing, inflation rates, and unemployment rates versus incidence and management of prostate cancers. They defined men managed with an initial conservative approach as those without surgery or radiation coding within 1 year of diagnosis.
Using a multivariate linear regression model, lead author Adam Weiner and colleagues found a positive correlation between per capita income and PSA screen-detected prostate cancer incidence (coefficient 79, 95% CI: 40.3 to 118, p<.001) and a trend toward significance for a correlation with S&P 500 closings (coefficient 5.18, 95% CI: –0.36 to 10.7). They also found significant correlations between use of initial conservative management and the negative economic indicators of unemployment rate (coefficient 78.3, 95% CI: 56.3 to 100.3, p<.001) and inflation rate (coefficient 28.6, 95% CI: 5.13 to 52.1, p<.05).
On multivariate analysis, they identified additional socioeconomic trends, including increased use of conservative management in non-Hispanic African-Americans (HR 1.74, 95% CI: 1.64-1.85, p<.001) and in older patients with yearly age as a continuous variable (HR 1.03, 95% CI: 1.03-1.04, p<.001). Those patients with intermediate- and high-risk prostate cancers were significantly less likely to undergo conservative management than those with low-risk disease (p<.001 for both). Similarly, those with Medicaid insurance or no insurance were also less likely to undergo initial curative intent therapy at all time points (p<.001 for both).
The authors then plotted personal income per capita versus new diagnoses of PSA-detected prostate cancer and showed a correlation with more men diagnosed as personal income increased (figure).
The authors concluded that the data set supported their original hypotheses; specifically, that during lean economic times fewer prostate cancers are screen diagnosed and those that are diagnosed are more likely to be conservatively managed. They also noted that being on public assistance insurance (Medicaid) or being without insurance similarly increased the likelihood that prostate cancer was managed conservatively.
Discussing the implications of the findings, Weiner said, “Prostate cancer screening and definitive treatment are subjects of controversy with questionable efficacy and increased cost. Thus, faced with financial insecurity, patients or practitioners may elect less expansive screening or treatment for prostate cancer, in aggregate.”
“To summarize our results, the incidence of cT1c prostate cancer correlated positively with national monthly income per capita, which should increase in times of a thriving economy, and negatively with inflation, an increase in which is associated with decreased financial security. Use of conservative management correlated positively with unemployment, an increase in which is associated with financial insecurity,” added Weiner, who worked on the study with Scott Eggener, MD, and Rena Conti, PhD.
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