Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Epidemiology

Five-year survival of patients with late-stage prostate cancer: comparison of the Military Health System and the U.S. general population

British Journal of Cancer volume 128, pages 1070–1076 (2023)Cite this article

Subjects

Abstract

Background

While the 5-year survival rate for local and regional prostate cancer is nearly 100%, it decreases dramatically for advanced tumours. Accessibility to health care is an important factor for cancer prognosis. The U.S. Military Health System (MHS) provides universal health care to its beneficiaries, reducing financial barriers to medical care. However, whether the universal care translates into improved survival among patients with advanced prostate cancer in the MHS is unknown. In this study, we compared the MHS and the U.S. general population in survival of patients with advanced prostate cancer (stages III and IV).

Methods

The MHS patients (N = 5379) were identified from the Department of Defense’s (DoD) Automated Central Tumor Registry (ACTUR). Patients in the U.S. general population (N = 21,516) were identified from the Surveillance, Epidemiology, and End Results (SEER) programme. The two populations were matched on age, race, and diagnosis year.

Results

The ACTUR patients exhibited longer 5-year survival than the matched SEER patients (HR = 0.74, 95% CI = 0.67–0.83), after adjustment for the potential confounders. The improved survival was observed for ages 50 years or older, both White patients and Black patients, all tumour stages and grades. This was also demonstrated despite the receipt of surgery or radiation treatment.

Conclusions

MHS beneficiaries with advanced prostate cancer had longer survival than their counterparts in the U.S. general population.

This is a preview of subscription content, access via your institution

Access options

Rent or buy this article

Get just this article for as long as you need it

$39.95

Learn more

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Kaplan–Meier survival curve for ACTUR and SEER patients with late-stage prostate cancer diagnosed during 1987–2013.

Data availability

The data sets generated during and/or analysed during the current study are not publicly available following DoD MHS regulations.

References

  1. Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2021. CA Cancer J Clin. 2021;71:7–33.

    Article  PubMed  Google Scholar 

  2. American Cancer Society. Survival rates for prostate cancer. 2021. https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/survival-rates.html. Accessed 12 May 2021.

  3. Walker GV, Grant SR, Guadagnolo BA, Hoffman KE, Smith BD, Koshy M, et al. Disparities in stage at diagnosis, treatment, and survival in nonelderly adult patients with cancer according to insurance status. J Clin Oncol. 2014;32:3118–25.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Lee JM, Wang X, Ojha RP. The effect of health insurance on childhood cancer survival in the United States. Cancer. 2017;123:4878–85.

    Article  PubMed  Google Scholar 

  5. Aizer AA, Falit B, Mendu ML, Chen MH, Choueiri TK, Hoffman KE, et al. Cancer-specific outcomes among young adults without health insurance. J Clin Oncol. 2014;32:2025–30.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Amini A, Yeh N, Jones BL, Bedrick E, Vinogradskiy Y, Rusthoven CG, et al. Perioperative mortality in nonelderly adult patients with cancer: a population-based study evaluating health care disparities in the United States according to insurance status. J Clin Oncol. 2018;41:476–84.

    Google Scholar 

  7. Ward EM, Fedewa SA, Cokkinides V, Virgo K. The association of insurance and stage at diagnosis among patients aged 55 to 74 years in the national cancer database. Cancer J. 2010;16:614–21.

    Article  PubMed  Google Scholar 

  8. Halpern MT, Ward EM, Pavluck AL, Schrag NM, Bian J, Chen AY. Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis. Lancet Oncol. 2008;9:222–31.

    Article  PubMed  Google Scholar 

  9. Slatore CG, Au DH, Gould MK. An official American Thoracic Society systematic review: insurance status and disparities in lung cancer practices and outcomes. Am J Respir Crit Care Med. 2010;182:1195–205.

    Article  PubMed  Google Scholar 

  10. Wu XC, Lund MJ, Kimmick GG, Richardson LC, Sabatino SA, Chen VW, et al. Influence of race, insurance, socioeconomic status, and hospital type on receipt of guideline-concordant adjuvant systemic therapy for locoregional breast cancers. J Clin Oncol. 2012;30:142–50.

    Article  PubMed  Google Scholar 

  11. Krimphove MJ, Cole AP, Fletcher SA, Harmouch SS, Berg S, Lipsitz SR, et al. Evaluation of the contribution of demographics, access to health care, treatment, and tumor characteristics to racial differences in survival of advanced prostate cancer. Prostate Cancer Prostatic Dis. 2019;22:125–36.

    Article  PubMed  Google Scholar 

  12. Mahal AR, Mahal BA, Nguyen PL, Yu JB. Prostate cancer outcomes for men aged younger than 65 years with Medicaid versus private insurance. Cancer. 2018;124:752–9.

    Article  PubMed  Google Scholar 

  13. Mahal BA, Aizer AA, Ziehr DR, Hyatt AS, Lago-Hernandez C, Chen YW, et al. The association between insurance status and prostate cancer outcomes: implications for the Affordable Care Act. Prostate Cancer Prostatic Dis. 2014;17:273–9.

    Article  CAS  PubMed  Google Scholar 

  14. Evaluation of the TRICARE program: fiscal year 2020 report to Congress. 2021. https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Health-Care-Program-Evaluation/Annual-Evaluation-of-the-TRICARE-Program. Accessed 13 Apr 2021.

  15. Lin J, Kamamia C, Brown D, Shao S, McGlynn KA, Nations JA, et al. Survival among lung cancer patients in the U.S. Military Health System: a comparison with the SEER population. Cancer Epidemiol Biomark Prev. 2018;27:673–9.

    Article  Google Scholar 

  16. Ru Y, Liu J, Fantacone-Campbell JL, Zhu K, Kovatich AJ, Hooke JA, et al. Comparative survival analysis of invasive breast cancer patients treated by a U.S. Military Medical Center and matched patients from the U.S. general population. Mil Med. 2017;182:e1851–8.

    Article  PubMed  Google Scholar 

  17. Lin J, McGlynn KA, Shriver CD, Zhu K. Comparison of survival among colon cancer patients in the U.S. Military Health System and patients in the Surveillance, Epidemiology, and End Results (SEER) Program. Cancer Epidemiol Biomark Prev. 2021;30:1359–65.

    Article  Google Scholar 

  18. Lin J, Bytnar JA, Theeler BJ, McGlynn KA, Shriver CD, Zhu K. Survival among patients with glioma in the US Military Health System: a comparison with patients in the Surveillance, Epidemiology, and End Results program. Cancer. 2020;126:3053–60.

    Article  PubMed  Google Scholar 

  19. Negoita S, Feuer EJ, Mariotto A, Cronin KA, Petkov VI, Hussey SK, et al. Annual Report to the Nation on the Status of Cancer, part II: recent changes in prostate cancer trends and disease characteristics. Cancer. 2018;124:2801–14.

    Article  PubMed  Google Scholar 

  20. Wong AT, Rineer J, Schwartz D, Becker D, Safdieh J, Osborn V, et al. Effect of thoracic radiotherapy timing and fractionation on survival in nonmetastatic small cell lung carcinoma. Clin Lung Cancer. 2017;18:207–12.

    Article  PubMed  Google Scholar 

  21. Registry groupings in SEER data and statistics. 2021. https://seer.cancer.gov/registries/terms.html. Accessed 12 Apr 2021.

  22. National Cancer Institute. Prostate cancer treatment - health professional version. Pathology. 2021. https://www.cancer.gov/types/prostate/hp/prostate-treatment-pdq#_1686_toc. Accessed 28 Jun 2021.

  23. World Health Organization. International classification of diseases for oncology, 3rd edition (ICD-O-3). 2021. https://apps.who.int/iris/bitstream/handle/10665/96612/9789241548496_eng.pdf. Accessed 13 Apr 2021.

  24. American Joint Committee on Cancer. AJCC cancer staging manual, sixth edition. In: Greene FL, Page DL, Flemming ID, et al. editors. Chicago, IL: Springer; 2002.

  25. American Cancer Society. Screening tests for prostate cancer: prostate-specific antigen (PSA) blood test. 2022. https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/tests.html. Accessed 19 Jan 2022.

  26. Barry MJ. Clinical practice. Prostate-specific-antigen testing for early diagnosis of prostate cancer. N Engl J Med. 2001;344:1373–7.

    Article  CAS  PubMed  Google Scholar 

  27. Wang M, Spiegelman D, Kuchiba A, Lochhead P, Kim S, Chan AT, et al. Statistical methods for studying disease subtype heterogeneity. Stat Med. 2016;35:782–800.

    Article  PubMed  Google Scholar 

  28. Mahal BA, Ziehr DR, Aizer AA, Hyatt AS, Sammon JD, Schmid M, et al. Getting back to equal: The influence of insurance status on racial disparities in the treatment of African American men with high-risk prostate cancer. Urol Oncol. 2014;32:1285–91.

    Article  PubMed  Google Scholar 

  29. Niu X, Roche LM, Pawlish KS, Henry KA. Cancer survival disparities by health insurance status. Cancer Med. 2013;2:403–11.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Fossati N, Nguyen DP, Trinh QD, Sammon J, Sood A, Larcher A, et al. The impact of insurance status on tumor characteristics and treatment selection in contemporary patients with prostate cancer. J Natl Compr Canc Netw. 2015;13:1351–8.

    Article  PubMed  Google Scholar 

  31. Fedewa SA, Etzioni R, Flanders WD, Jemal A, Ward EM. Association of insurance and race/ethnicity with disease severity among men diagnosed with prostate cancer, National Cancer Database 2004-2006. Cancer Epidemiol Biomark Prev. 2010;19:2437–44.

    Article  Google Scholar 

  32. Liu W, Goodman M, Filson CP. Association of state-level Medicaid expansion with treatment of patients with higher-risk prostate cancer. JAMA Netw Open. 2020;3:e2015198.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Beebe-Dimmer JL, Ruterbusch JJ, Cooney KA, Bolton A, Schwartz K, Schwartz AG, et al. Racial differences in patterns of treatment among men diagnosed with de novo advanced prostate cancer: a SEER-Medicare investigation. Cancer Med. 2019;8:3325–35.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Potosky AL, Merrill RM, Riley GF, Taplin SH, Barlow W, Fireman BH, et al. Prostate cancer treatment and ten-year survival among group/staff HMO and fee-for-service Medicare patients. Health Serv Res. 1999;34:525–46.

    CAS  PubMed  PubMed Central  Google Scholar 

  35. Sadetsky N, Elkin EP, Latini DM, DuChane J, Carroll PR. Prostate cancer outcomes among older men: insurance status comparisons results from CaPSURE database. Prostate Cancer Prostatic Dis. 2008;11:280–7.

    Article  CAS  PubMed  Google Scholar 

  36. Grossman DC, Curry SJ, Owens DK, Bibbins-Domingo K, Caughey AB, Davidson KW, et al. Screening for prostate cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319:1901–13.

    Article  PubMed  Google Scholar 

  37. The evaluation of the TRICARE program: fiscal year 2019 report to Congress. 2019. https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Health-Care-Program-Evaluation/Annual-Evaluation-of-the-TRICARE-Program. Accessed 24 Jul 2019.

  38. Prostate cancer exams. TRICARE Covered Services. 2021. https://www.tricare.mil/CoveredServices/IsItCovered/ProstateCancerExams. Accessed 12 May 2021.

  39. Optenberg SA, Thompson IM, Friedrichs P, Wojcik B, Stein CR, Kramer B. Race, treatment, and long-term survival from prostate cancer in an equal-access medical care delivery system. JAMA. 1995;274:1599–605.

    Article  CAS  PubMed  Google Scholar 

  40. Riviere P, Luterstein E, Kumar A, Vitzthum LK, Deka R, Sarkar RR, et al. Survival of African American and non-Hispanic white men with prostate cancer in an equal-access health care system. Cancer. 2020;126:1683–90.

    Article  CAS  PubMed  Google Scholar 

  41. Graham-Steed T, Uchio E, Wells CK, Aslan M, Ko J, Concato J. ‘Race’ and prostate cancer mortality in equal-access healthcare systems. Am J Med. 2013;126:1084–8.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Daskivich TJ, Kwan L, Dash A, Litwin MS. Racial parity in tumor burden, treatment choice and survival outcomes in men with prostate cancer in the VA healthcare system. Prostate Cancer Prostatic Dis. 2015;18:104–9.

    Article  CAS  PubMed  Google Scholar 

  43. Alexander M, Zhu K, Cullen J, Byrne C, Brown D, Shao S, et al. Race and overall survival in men diagnosed with prostate cancer in the Department of Defense Military Health System, 1990-2010. Cancer Causes Control. 2019;30:627–35.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank the Joint Pathology Center and the Surveillance, Epidemiology, and End Results (SEER) programme for the use of the cancer registry data.

Funding

This project was supported by John P. Murtha Cancer Center Research Program, Uniformed Services University of the Health Sciences under the auspices of the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.

Author information

Authors and Affiliations

  1. Murtha Cancer Center/Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA

    Jie Lin, Craig D. Shriver & Kangmin Zhu

  2. Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA

    Jie Lin, Craig D. Shriver & Kangmin Zhu

  3. Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, MD, USA

    Jie Lin & Kangmin Zhu

  4. Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA

    Jie Lin, Darryl Nousome, Jiji Jiang & Kangmin Zhu

  5. Center for Prostate Disease Research, Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA

    Darryl Nousome, Jiji Jiang & Gregory T. Chesnut

  6. Urology Service, Walter Reed National Military Medical Center, Bethesda, MD, USA

    Gregory T. Chesnut

Authors
  1. Jie Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Darryl Nousome
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jiji Jiang
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gregory T. Chesnut
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Craig D. Shriver
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Kangmin Zhu
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Each of the authors (JL, DN, JJ, GTC, CDS, and KZ) significantly contributed to the project conception that led to data acquisition and results interpretation. All authors contributed to manuscript drafting, revision, and final approval. The corresponding author (KZ) confirmed that he had full access to the data in the study and final responsibility for the decision to submit for publication.

Corresponding author

Correspondence to Kangmin Zhu.

Ethics declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

This study was based on the non-identifiable ACTUR data and SEER de-identified public use data. The study was approved by the institutional review board of Walter Reed National Military Medical Center. The study was performed in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lin, J., Nousome, D., Jiang, J. et al. Five-year survival of patients with late-stage prostate cancer: comparison of the Military Health System and the U.S. general population. Br J Cancer 128, 1070–1076 (2023). https://doi.org/10.1038/s41416-022-02136-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41416-022-02136-3

Search

Advanced search

Quick links