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Prostate cancer outcomes among older men: insurance status comparisons results from CaPSURE database

Prostate Cancer and Prostatic Diseases volume 11, pages 280–287 (2008)Cite this article

Abstract

With growing number of older adults in the United States and complexity of issues related to Medicare and other insurances more research is needed to evaluate an effectiveness of the different insurance types in prevention, screening and treatment of cancer. With prostate cancer being highly prevalent disease in older men, the importance of appropriate treatment and favorable outcomes is imperative. In this study we examine whether prostate cancer outcomes, such as risk category at diagnosis, treatment and survival differ in relationship to insurance status in older patients in CaPSURE. Data were abstracted from CaPSURE, a longitudinal observational database of 13 124 men with prostate cancer. Men were selected for the study if they were older than 65 years old at diagnosis, newly diagnosed between 1995 and 2005 at entry to CaPSURE with localized disease and received radical prostatectomy (RP), external beam radiation (EBRT), brachytherapy (BT), hormonal therapy or expectant management (EM). Insurance status was summarized by eight categories: Medicare only, Medicare+supplement, Medicare+HMO, Medicare+PPO, Medicare+FFS, health maintenance organization (HMO), preferred provider organization (PPO) and Veteran's Administration (VA). A total of 2983 men met the inclusion criteria. Odds ratios (OR) for the likelihood of receiving each type of therapy compared to RP by insurance status and likelihood of presenting with high-risk classification at diagnosis were derived using multinomial logistic regression, adjusting for clinical and demographic characteristics. Difference in survival between insurance groups was evaluated by Cox's multivariate regression. Multivariate analysis demonstrated a strong association between initial treatment and insurance status. Compared to Medicare patients, men in the CaPSURE database treated at HMO, PPO and VA systems were more likely to receive BT than RP (OR, 1.71–1.92) and less likely to receive this treatment if they were in Medicare+FFS and Medicare+PPO (OR, 0.18–0.38). Hormonal treatment demonstrated similar pattern, however OR did not reached statistical significance for HMO and PPO. Use of EM was much more predominant for patients in VA system (OR, 4.74; 95% CI, 1.94–11.55). Use of EBRT was significantly associated with type of insurance. Men with VA, Medicare+FFS and Medicare+PPO insurance were less likely to receive this treatment compared to RP. Survival and clinical risk at diagnosis was associated with insurance status in univariate analysis but this association diminished after adjusting for possible covariates. This study provides important information on relationship between insurance status and several outcomes in patients with prostate cancer. Even after controlling for important clinical and sociodemographic factors we found marked differences in prostate cancer treatment according to type of insurance. Future explorations of associations between health care delivery system, cancer care and outcomes are needed.

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Acknowledgements

The current CaPSURE Investigators are as follows: Peter R Carroll, MD (University of California, San Francisco, CA), James S Cochran, MD (Urology Clinics of North Texas, Dallas, TX), Christopher J Kane, MD (Veterans Administration Medical Center, San Francisco, CA), Donald P Finnerty, MD (PAPP Clinic, Newnan, GA), Eugene V Kramolowsky, MD (The Virginia Urology Center, Richmond, VA), Robert M Segaul, MD (Urology Associates of West Broward Belle Terre, Sunrise, FL), Paul Sieber, MD (Urological Associates of Lancaster, Lancaster, PA), Stanley A Brosman, MD (Pacific Clinical Research, Santa Monica, CA), Lynn W Conrad, MD (Urology Center of the South, PC, Memphis, TN), Joseph N Macaluso, Jr, MD, (Urologic Institute of New Orleans, Gretna, LA), Michael Flanagan, MD (Urology Specialists, Waterbury, CT), Jeffrey K Cohen, MD (Triangle Urology Group, Pittsburgh, PA), Jerrold Sharkey, MD (Urology Health Center, New Port Richey, FL), Thomas W Coleman, MD (Mobile Urology Group, Mobile, AL), Elliott C Silbar, MD (Clinic of Urology, Milwaukee, WI), Paul S Ray, DO (Cook County Hospital, Chicago, IL), David Noyes, MD (Berkshire Urological Associates, PC, Pittsfield, MA), Mohammed Mostafavi, MD (Urology Group of Western New England, Springfield, MA), Louis Keeler, III, MD (Center for Urologic Care, Voorhees, NJ), James Gottesman, MD (Seattle Urological, Seattle, WA), Bhupendra M Tolia, MD (Associated Advanced Adult & Pediatric Urology, Bronx, NY), W Lamar Weems, MD (Mississippi Urology, Jackson, MS), Glen Wells, MD (Alabama Urology, Birmingham, AL), Richard J Kahnoski, MD (Michigan Medical, Grand Rapids, MI), Sheldon J Freedman, MD (Las Vegas, NV), Randil Clark, MD (North Idaho Urology, Coeur D'Alene, ID), David Penson, MD, MPH (Veterans Administration Puget Sound HCS, Seattle, WA), Mark Austenfeld, MD (Kansas City Urology Care, Kansas City, MO), Henri P Lanctin, MD (Adult & Pediatric Urology, St Cloud, MN), J Brantley Thrasher, MD (University of Kansas, Kansas City, KS) and David W Bowyer, MD (Snake River Urology, Twin Falls, ID). Former CaPSURE investigators are as follows: John Forrest, MD (1995–1999, Urologic Specialists of Oklahoma, Tulsa, OK), William Schmeid, MD (1995–1999, Metro Urology, Jeffersonville, IN), Glen Brunk, MD (1995–1999, Urology of Indiana, Indianapolis, IN), Jay Young, MD (1995–2001, South Orange County Medical Research Center, Laguna Woods, CA), Gary Katz, MD (1996–2000, Medical College of Virginia and Veterans Administration Medical Center, Richmond, VA), Stacy J Childs, MD (1999–2000, Cheyenne Urological, Cheyenne, WY), Kevin Tomera, MD (1999–2001, Alaska Urological Associates, Anchorage, AK), Clayton Hudnall, MD (1995–2002, Urology San Antonio Research, San Antonio, TX). CaPSURE is supported by TAP Pharmaceutical Products Inc. Also supported by Specialized Program of Research Excellence (SPORE) grant P50 C89520 to the University of California, San Francisco from the National Institutes of Health/National Cancer Institute.

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Authors and Affiliations

  1. Department of Urology, Genitourinary Cancer Epidemiology and Population Sciences (1) Program, UCSF Comprehensive Cancer Center, University of California San Francisco, CA, USA

    N Sadetsky, E P Elkin, D M Latini & P R Carroll

  2. Scott Department of Urology and Dan L Duncan Cancer Center, Baylor College of Medicine, and Houston Center for Quality of Care and Utilization Studies, Michael E DeBakey VA Medical Center, University of California, San Francisco, CA, USA

    D M Latini

  3. TAP Pharmaceutical Products Inc, Lake Forest, IL, USA

    J DuChane

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Sadetsky, N., Elkin, E., Latini, D. et al. Prostate cancer outcomes among older men: insurance status comparisons results from CaPSURE database. Prostate Cancer Prostatic Dis 11, 280–287 (2008). https://doi.org/10.1038/sj.pcan.4501015

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