Clinical setting, provider “bias,” and treatment selection for economically disadvantaged patients

A study of prostate cancer treatments provided to economically disadvantaged men with relatively advanced forms of prostate cancer (compared to the average in the US today) suggests that where they were treated had at least as much (and probably more) impact on their treatment as their actual clinical condition.

Now we should be clear up front that this study was carried out using only data from 559 patients enrolled in the California IMPACT program and treated between 2001 and 2006. The IMPACT program is a state-specific initiative designed to provide free prostate cancer services for the economically disadvantaged in California. It would be inappropriate to generalize from this information to suggest (necessarily) that it applied to all prostate cancer patients in either California or the USA. However, some of the findings are at least “informative.”

The actual abstract of the original paper by Parsons et al. does not (yet) appear to be available on line. However, according to an article on MedPage Today (based, presumably, on information provided to the media by the publisher of Cancer), among the program enrollees studied:

  • Patients treated at private hospitals (as opposed to publicly funded county hospitals) were more than twice as likely to receive radiation therapy and more than four and a half times as likely to receive primary androgen deprivation therapy compared to surgery.
  • This result was independent of the age, race, comorbidity status, clinical tumor stage, Gleason sum, and D’Amico risk stratification of the patients.
  • The patients treated at the private hospitals were more likely to be white.

Parson’s and his colleagues are quoted as writing that, “A likely explanation for this imparity is that the initial provider in the county hospitals was always a urologist, whereas at the private venues the initial providers were a mix of urologists, radiation oncologists, and medical oncologists.”

Among the IMPACT enrollees studied by Parsons et al., 315 received treatment from county hospitals and 244 received care from private facilities.

The authors are also quoted as writing that, “These data reveal substantial variations in treatment patterns between different types of healthcare institutions that — given the implications for health policy and quality of care — merit further scrutiny.”

The “New” Prostate Cancer InfoLink has long advocated for a system whereby patients diagnosed with localized prostate cancer be given access to multiple care providers (ideally in some form of multidisciplinary prostate cancer center) so that they will be exposed to a variety of opinions and information about their disease and its management. Current community-based care tends to drive patients to get the form of treatment proposed by the first clinician they see (usually a urologist) without having the opportunity to learn that they have multiple options — most especially including active surveillance (a form of disease monitoring) as opposed to immediate surgical or radiotherapeutic intervention. We need to do better.

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