Effect of race on thyroid cancer care in an equal access healthcare system

Background

Thyroid cancer is more likely to present at an advanced age with larger tumor size in black patients. The aim of this study was to assess the influence of race on the presentation, treatment, and survival in an equal access healthcare system.

Methods

This retrospective study included all black and white patients with thyroid cancer who were treated at a Department of Defense facility from 1986 to 2008. Patients' age, tumor size, lymph node status, treatment, and survival were compared.

Results

A total of 4,625 patients were identified. There was no difference between black and white patients in regards to age at presentation, tumor size, use of surgical and/or radiation therapy, and overall 5-year survival rate. Black patients had a lower rate of lymph node involvement.

Conclusions

In an equal access healthcare system, black patients have similar disease presentation, undergo similar treatment, and have the same survival as white patients.     

Prostate cancer screening in the Prostate,Lung, Colorectal and Ovarian cancer screening trial: update on findings from the initial four rounds of screening in a randomized trial

OBJECTIVE

To describe the results of the first four rounds (T0‐T3) of prostate cancer screening in the Prostate, Lung, Colorectal and Ovarian (PLCO) cancer screening trial (designed to determine the value of screening in the four cancers), that for prostate cancer is evaluating whether annual screening with prostate‐specific antigen (PSA) and a digital rectal examination (DRE) reduces prostate cancer‐specific mortality.

SUBJECTS AND METHODS

In all, 38 349 men aged 55–74 years were randomized to undergo annual screening with PSA (abnormal >4.0 ng/mL) and a DRE. The follow‐up of abnormal screening results was at the discretion of subjects’ physicians. PLCO staff obtained records related to diagnostic follow‐up of positive screen results.

RESULTS

Compliance with screening decreased slightly from 89% at baseline to 85% at T3. Both PSA positivity rates (range 7.7–8.8% at T0‐T3) and DRE positivity rates (range 6.8–7.6% at T0‐T3) were relatively constant over time. The positive predictive value (PPV) of a PSA level of >4.0 ng/mL decreased from 17.9% at T0 to 10.4–12.3% at T1‐T3; the PPV for DRE (in the absence of a positive PSA test) was constant over time (2.9–3.6%). Cancer was diagnosed in 1902 men (4.9%). Screen‐detected cancers at T0 (549) were more likely to be clinical stage III/IV (5.8%) and to have a Gleason score of 7–10 (34%) than screen‐detected cancers at T1‐T3 (1.5–4.2% stage III/IV and 24–27% Gleason score 7–10 among 1054 cases).

CONCLUSION

The present findings on serial prostate screening are similar to those reported from other multi‐round screening studies. Determining the effect of PSA screening on prostate cancer mortality awaits further follow‐up.     

Outcome comparison following colorectal cancer surgery in an equal access system

Background

Previous reports suggest outcome differences following surgery for colorectal cancer (CRC) based on specialist and volume-related metrics. We sought to compare community and tertiary centers in an equal access system.

Materials and methods

Patients treated for CRC at Department of Defense medical facilities were stratified by care at tertiary (MEDCEN) versus community (MEDDAC) medical centers. Disease-free and overall survival outcomes were calculated, including Cox multivariate analysis.

Results

A total of 6438 patients met inclusion criteria. Overall, 3347 operations were performed at MEDCENs and 3091 operations at MEDDACs. By stage, 25.6% were stage 1, 27.1% stage 2, 29.1% stage 3, and 18.2% stage 4. Mean number of lymph nodes harvested were 11.3 ± 10.2, with no difference between facilities. Disease-free survival at 5 y was similar between the two cohorts (mean 88.1%). Overall 5-y survival was 52.7% (MEDDAC) versus 46.8% (MEDCEN), P < 0.001, due to significant differences in stage 2 patients. Cox regression and logistic regression analysis identified stage 2 patients as independently associated with significantly increased 5-y mortality risk at MEDCEN.

Conclusion

Outcomes following surgery for CRC in an equal access system are improved in stage 2 patients treated at MEDDACs compared to high-volume, specialist-centered MEDCENs. Further evaluation into factors impacting improved overall survival at MEDDACs, including adjuvant therapy utilization, is warranted to optimize outcomes.     

Type 2 diabetes among Asian Americans: Prevalence and prevention

Type 2 diabetes mellitus (T2DM) is a growing problem among Asian Americans. Based on the Centers for Disease Control, the age-adjusted prevalence of T2DM for Asian Americans is 9%, placing them at “moderate risk”. However differential patterns of disease burden emerge when examining disaggregated data across Asian American ethnic groups; with Filipino, Pacific Islander, Japanese, and South Asian groups consistently described as having the highest prevalence of T2DM. Disentangling and strengthening prevalence data is vital for on-going prevention efforts. The strongest evidence currently available to guide the prevention of T2DM in the United States comes from a large multicenter randomized clinical control trial called the Diabetes Prevention Program, which targets individual lifestyle behavior changes. It has been translated and adopted for some Asian American groups, and shows promise. However stronger study designs and attention to several key methodological considerations will improve the science. Increased attention has also been directed toward population level downstream prevention efforts. Building an infrastructure that includes both individual and population approaches is needed to prevent T2DM among Asian American populations, and is essential for reducing health disparities.     

Prostate cancer in Honolulu, Hawaii: pathological and clinical characteristics

We reviewed trends in prostate cancer at our institution to determine if there are changing characteristics that need to be considered in conducting comparative studies with patients from other institutions. Assessed between 1993 and 1998 were trends in PSA status, race, tumour grade, clinical stage and treatment. The incidence dropped between 1993 and 1994, but has remained stable since, except in Philipinos. Changes in clinical tumour stage and PSA positive rate were not noted; Gleason score distribution changed with marked decline of low grade tumours. This reflects the tendency pathologists had of undergrading prostatic adenocarcinoma in biopsy specimens during the early 1990s. Use of hormonal treatment increased from 21% to 57%. Patients receiving radiation therapy also increased slightly. Comparative studies between institutions would require review of the biopsy material for accurate Gleason scores. Outcome studies would need to control for the changing pattern of prostate cancer therapy.     

Socioeconomic status,race, and long-term outcomes after radical prostatectomy in an equal access health system: Results from the SEARCH database

Introduction

We previously found racial differences in biochemical recurrence (BCR) after radical prostatectomy (RP) persisted after adjusting for socioeconomic status (SES) while SES did not predict BCR. The impact on long-term prostate cancer (PC) outcomes is unclear. We hypothesized higher SES would associate with better long-term outcomes regardless of race.

Prostate cancer outcomes following whole-gland and focal high-intensity focused ultrasound

Objective

To report the 5-year failure-free survival (FFS) following high-intensity focused ultrasound (HIFU).

Patients and Methods

This observational cohort study used linked National Cancer Registry data, radiotherapy data, administrative hospital data and mortality records of 1381 men treated with HIFU for clinically localised prostate cancer in England. The primary outcome, FFS, was defined as freedom from local salvage treatment and cancer-specific mortality. Secondary outcomes were freedom from repeat HIFU, prostate cancer-specific survival (CSS) and overall survival (OS). Cox regression was used to determine whether baseline characteristics, including age, treatment year, T stage and International Society of Urological Pathology (ISUP) Grade Group were associated with FFS.

Results

The median (interquartile range [IQR]) follow-up was 37 (20–62) months. The median (IQR) age was 65 (59–70) years and 81% had an ISUP Grade Group of 1–2. The FFS was 96.5% (95% confidence interval [CI] 95.4%–97.4%) at 1 year, 86.0% (95% CI 83.7%–87.9%) at 3 years and 77.5% (95% CI 74.4%–80.3%) at 5 years. The 5-year FFS for ISUP Grade Groups 1–5 was 82.9%, 76.6%, 72.2%, 52.3% and 30.8%, respectively (P < 0.001). Freedom from repeat HIFU was 79.1% (95% CI 75.7%–82.1%), CSS was 98.8% (95% CI 97.7%–99.4%) and OS was 95.9% (95% CI 94.2%–97.1%) at 5 years.

Conclusion

Four in five men were free from local salvage treatment at 5 years but treatment failure varied significantly according to ISUP Grade Group. Patients should be appropriately informed with respect to salvage radical treatment following HIFU.     

Screening for prostate cancer: an updated Cochrane systematic review

OBJECTIVE

? To determine whether screening for prostate cancer reduces prostate cancer‐specific mortality, impact on all‐cause mortality and patient health‐related quality of life.

MATERIALS AND METHODS

? An update to our 2006 Cochrane systematic review was performed by re‐running an updated search of several databases, including MEDLINE and the Cochrane CENTRAL Register of Controlled Trials. ? Articles were included if they were a randomized controlled trial (RCT) examining screening vs no screening for prostate cancer. Data was collected and analysed according to the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

? Five RCTs with a total of 341 351 participants were included in this updated Cochrane systematic review. All involved PSA testing, although the interval and threshold for further evaluation varied across trials. The age of participants was 50–74 years, with durations of patient follow‐up of 7–15 years. ? The methodological quality of three of the studies was assessed as posing a high risk of bias. ? Meta‐analysis of the five included studies indicated no statistically significant difference in prostate cancer‐specific mortality between men randomized to screening and control [relative risk (RR) 0.95, 95% CI 0.85–1.07]. Sub‐group analyses indicated that prostate cancer‐specific mortality was not affected by age at which participants were screened. A pre‐planned analysis of a ‘core’ age group of men aged 55–69 years from the largest RCT (European Randomised Study of Screening for Prostate Cancer) reported a significant 20% relative reduction in prostate cancer‐specific mortality; (95% CI 0.65–0.98; absolute risk 0.71 per 1000 men). The number of men diagnosed with prostate cancer was significantly greater in men randomized to screening, compared with those randomized to control (RR 1.35, 95% CI 1.06–1.72). ? Harms of screening included high rates of false‐positive results for the PSA test, over‐diagnosis and adverse events associated with transrectal ultrasonography guided biopsies such as infection, bleeding and pain.

CONCLUSIONS

? Prostate cancer screening did not significantly decrease all‐cause or prostate cancer‐specific mortality in a combined meta‐analysis of five RCTs. ? Any benefits from prostate cancer screening may take >10 years to accrue; therefore, men who have a life expectancy of <10–15 years should be informed that screening for prostate cancer is not beneficial and has harms.     

Tyrol Prostate Cancer Demonstration Project: early detection, treatment, outcome, incidence and mortality

OBJECTIVE

To evaluate the effectiveness of a well‐controlled programme of early detection and treatment of prostate cancer in the population of Tyrol, Austria, where such a programme of early detection and treatment was initiated in 1988 and where prostate‐specific antigen (PSA) testing was offered for free to all men aged 45–75 years from 1993.

SUBJECTS AND METHODS

Comparison of prostate cancer mortality rates in Tyrol and the rest of Austria was accomplished through a generalized additive model. A piecewise linear change‐point Poisson regression model was used to compare mortality rates in Tyrol and the rest of Austria. Standardized mortality ratios were calculated with reference to the mortality rates in 1986–1990.

RESULTS

In all, 86.6% of eligible men have been tested at least once since 1993. Cancer deaths in Tyrol in 2005 were 54% (95% confidence interval [CI] 34–69%) lower than expected compared with 29% (95% CI 22–35%) in the rest of Austria. The decreasing trend in prostate cancer mortality was significantly greater in Tyrol compared with the rest of Austria (P = 0.001). A significant migration to lower stage disease occurred and radical prostatectomy was associated with low morbidity.

CONCLUSIONS

In the Tyrol region where treatment is freely available to all patients, where widespread PSA testing and treatment with curative intent occurs, there was a reduction in prostate cancer mortality rates which was significantly greater than the reduction in the rest of Austria. This reduction in prostate cancer mortality is most probably due to early detection, consequent down‐staging and effective treatment of prostate cancer.     

Clinical-pathological comparison of clinical prostate cancer between Japanese Americans in Hawaii and Japanese living in Japan

In an attempt to determine the role of environmental factors in the etiology of prostate cancer, we compared the clinical-pathological findings of prostate cancer among Japanese Americans in Hawaii and Japanese living in Japan. Our study showed that prostate cancer in Japanese living in Japan is more advanced than in Japanese Americans. The findings indicate that screening for prostate cancer in Japan is far behind that in the USA. The difference in level of cancer screening also precluded our attempt to analyse environmental factors contributing to prostate cancer progression in the two groups. The variation in method of clinical detection of prostate cancer between the USA and Japan is also likely to contribute to the apparent difference in the incidence of the disease.     

Race does not impact colorectal cancer treatment or outcomes with equal access

Background

Ethnicity is implicated as a factor for disparate outcomes in colorectal cancer. We sought to evaluate this relationship at a military medical center organized to deliver equitable health care.

Methods

Retrospective analysis of colorectal cancer patients comparing demographics, grade, American Joint Committee on Cancer (AJCC) stage, and adjuvant therapy.

Results

From January 1994 to January 2004, 398 patients were treated with colorectal cancer (74 [19%] nonwhites). Comparatively, nonwhites were younger and had fewer stage II tumors with a increased proportion of stage III tumors (P < .01). With a median follow-up period of 52 (0-151) months, there were no disparities in surgical resection, adjuvant therapy, or disease recurrence. Kaplan-Meier analysis revealed no disparity in disease-free and cancer-specific survival (P = .585 and P = .132); Cox regression revealed increased age and AJCC stage III as the only independent predictors of lower survival (P < .05).

Conclusions

Ethnicity was associated with differences in age and AJCC stage at presentation. In an equitable health care system, these differences did not impact patients' treatment or survival.     

Prostate cancer incidence,stage at diagnosis,treatment and survival in ethnic groups in South‐East England

Study Type – Prevalence (prospective cohort)
Level of Evidence 1b

OBJECTIVES

To use self‐assigned ethnicity to examine patterns of incidence, stage, treatment and survival in patients with prostate cancer in South‐east England.

PATIENTS AND METHODS

Data on 36 961 men resident in South‐east England and diagnosed with prostate cancer between 1998 and 2003 were extracted from the Thames Cancer Registry. Ethnicity information was obtained from the Hospital Episode Statistics dataset, and matched to the cancer records. The ethnic groups examined were White (19 688), Black (1422) and Indian/Pakistani (397). Age‐standardized incidence rate ratios were calculated overall and for narrower age groups, with White men as the baseline group. Logistic regression was used to assess whether patients had a stage of disease recorded at diagnosis, if so whether it was metastatic, and to examine treatment received. To assess overall and prostate cancer‐specific survival (PCSS), Cox regression models were fitted, adjusting sequentially for age, socioeconomic status, treatment received and stage of disease at diagnosis.

RESULTS

Indian/Pakistani men had a lower age‐standardized rate than White men (rate ratio 0.69, 95% confidence interval 0.63–0.75), while Black men had a higher rate ratio (2.51, 2.30–2.73). There was no difference in the proportion of men diagnosed with metastatic disease in each ethnic group. There was variation in recorded surgery and hormone treatment. Indian/Pakistani men had better PCSS than White men (fully adjusted hazard ratio 0.76, P = 0.024). There was no difference in PCSS between Black and White men (hazard ratio 0.93, P = 0.238).

CONCLUSIONS

Black men had the highest incidence of prostate cancer, followed by White, then Indian/Pakistani men. The relative excess of prostate cancer in Black vs White men was strongly age‐dependent. Despite differences in recorded treatment, Indian/Pakistani men had better overall survival and PCSS. Black men also had better overall survival, and their PCSS was similar to that of White men. This might be due to access to the publicly funded National Health Service in the UK.     

Improved rates of colorectal cancer screening in an equal access population

Background

National colorectal cancer (CRC) screening averages 50% to 60%. We aimed to identify screening prevalence in select Department of Defense (DOD) beneficiaries with equal access to care.

Methods

December 2007 cross-sectional data of patients over 50 years of age included patient demographics, screening modality, and compliance.

Results

Of 17,252 patients (52% male; mean age 63.2 ± 8.1 years), 12,229 (71%) were up-to-date with national screening guidelines. Modalities included colonoscopy (83.0%), flexible sigmoidoscopy with fecal occult blood testing (FOBT) (32.2%), and air-contrast barium enema (0.7%). African American or Hispanic background (70% African American, 68% Hispanic vs 73% Caucasian), younger patients (66.1% <65 years vs 78.6% >65 years), and male gender (69.9% vs 72.1%; all P < .001) all had lower rates. Compared to 2005, more patients were current with guidelines (71% vs 64%) and colonoscopic screening (83% vs 71%).

Conclusions

Although ethnicity-, gender-, and age-related disparities were observed, screening rates are improved in an equal access healthcare system.