Variations In Quality Of Care For Men With Early-Stage Prostate Cancer

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;  Cancer / Oncology
Article Date: 25 Aug 2008 - 1:00 PDT

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UroToday.com - A study in the August 1, 2008 edition of the Journal of Clinical Oncology by Dr. Benjamin A. Spencer and collaborators suggests that significant inconsistencies in prostate cancer care exist at a national level in the U.S.

The researchers used the National Cancer Data Base (NCDB), established in 1989 by the American College of Surgeons and the American Cancer Society. This database contains hospital-based information on cancer diagnosis, management, and outcomes with a goal of establishing regional and national benchmarks against which hospitals can compare their care patterns and outcomes. The database has been shown to be similar to SEER with regard to patient and disease characteristics. From 2000-2001 the NCDB collected information on 70% of all prostate cancer cases in the US. Three strata in quality of care were evaluated; patient race, hospital location, and hospital type. The hospital type was based on established categories from the Commission on Cancer's approvals program and included teaching hospitals associated with a medical school (that perform clinical research), comprehensive cancer centers (which treat at least 650 cancer cases annually and participate in clinical research), and community cancer centers (which treat between 100 and 649 new cancer cases annually).

A file of 117,953 cases of prostate cancer diagnosed during 2000-2001 was extracted from the NCDB. A 5% stratified random sample of cases was developed, and selected cases were submitted to hospitals from which 92.5% had data received for abstraction. The analytic sample represented 55,160 cases; the average patient age was 66.4 years, and 85% of patients were Caucasian. The pre-treatment PSA level was below 10ng/ml in 72.7% of cases, 60% had a clinical stage T1 tumor, 80% of biopsies had Gleason score 6 or 7, and 41% had no comorbid disease. Caucasian patients were older than African-American patients (66.9 vs. 64 years), had lower PSA levels (9.0 vs. 12.7ng/ml, respectively), had less comorbidity, and were more likely to have Medicare coverage. Teaching hospitals tended to care for younger men (65.2 years) compared to community cancer centers (66.5 years) or comprehensive cancer centers (67.5 years). Teaching hospitals also treated lower-stage disease and included more Veterans' Administration and managed care coverage. The Great Lakes region of the U.S. had fewer men with stage T2 disease compared with the Southeast region.

A racial difference in compliance for quality indicators was not demonstrated, however significant variations were observed by hospital type and census division. Comprehensive cancer centers and teaching hospitals had higher compliance rates than community cancer centers in all of the structural indicators and in five of the pre-therapy assessment indicators. Examples of this included documentation of clinical stage, family history of prostate cancer, urinary, sexual and bowel function, rectal protection, board certification of urologists, and radiation oncologists.

This study suggests that the necessary environment for the provision of high-quality care is generally available. However, certain aspects of a high-quality environment such as the availability of board-certified specialists, psychological counseling and conformal radiotherapy are more prevalent at teaching hospitals or comprehensive cancer centers.

Spencer BA, Miller DC, Litwin MS, Ritchey JD, Stewart AK, Dunn RL, Gay EG, Sandler HM, Wei JT.
J Clin Oncol. 2008 Aug 1;26(22):3735-42

Reported by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS

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