Low-income prostate cancer patients are far more likely to undergo surgery for their disease if they are treated in a county hospital versus a private provider.
The difference may be explained by the specialty of the physician that patients last saw before selecting treatment, say the authors of the multicenter study, which was published in Cancer (2010; 116:1378-84).
Of the 559 men in the study, 315 (56%) received treatment in county hospitals, while 244 (44%) were treated in private facilities. "County hospitals," in this case, were defined as institutions primarily funded by local or state governments to care for otherwise underserved populations.
The authors referred to their study as the first to compare prostate cancer treatments between private and public institutions.
"I honestly would have hypothesized that there would be no difference between the two types of health care venues," said first author J. Kellogg Parsons, MD, assistant professor of surgery/urology at the University of California, San Diego. "And even when we subsequently adjusted for all of the confounders-like severity of cancer, age, and health status-we found that the association still held up."
Men in the study were enrolled in a state-funded program for low-income patients known as IMPACT (Improving Access, Counseling, and Treatment for Californians with Prostate Cancer). There were no significant differences between the publicly and privately treated patients with respect to age, comorbidities, Gleason sum, T stage, or PSA.
Provider specialty plays key role
Dr. Parsons and his colleagues suspect that provider specialty played a substantial role in the outcomes. At county hospitals, patients were generally seen by urologic surgeons, whereas at private institutions, patients' initial points of contact were a mix of urologists, oncologists, and radiation oncologists.
All patients in the study were offered a second opinion if they desired, but there was no way of tracking how many men actually took advantage of the offer.
"As a specialty, urologists need to be very sensitive to the idea that patients need second opinions with different specialists," Dr. Parsons said. "So if the initial point of contact is a urologist, the patient should see a radiation oncologist, too. That should be built into the consultation paradigm.
"That's important because prior research shows that some prostate cancer patients have significant regrets after undergoing treatment. If we're able to enhance preoperative counseling through access to multiple types of providers, we potentially may enhance post-treatment quality of life and reduce factors like treatment regret."
Dr. Parsons pointed out that this question also deserves further scrutiny due to the fact that county hospitals are funded with taxpayer dollars, which means there are implications for health policy.
"To be fair, as physicians we all carry certain intellectual biases," he said. "For example, when urologists look at published research comparing surgery and radiation, we may walk away with different conclusions than radiation oncologists simply because of our disparate training backgrounds. These conclusions, in turn, may influence the ways in which we counsel our patients."
Dr. Parsons' group also found that participants treated by private providers were more likely to be Caucasian than those seen at county hospitals (35% vs. 10%, p<.01).