Thomas E. Moody, M.D. (205) 930-0920

Disparities in

Prostate Cancer Care:

The Alabama Experience

After participating in this CME activity, participants should be able to:

Identify the major disparities in prostate cancer care in Alabama and their possible causes

Describe the steps that are being taken to narrow the disparities in prostate cancer care in Alabama and the challenges in making further improvements

Learning Objectives

In 2006 the National Prostate Cancer Coalition issued a report assessing each of the 50 states and the District of Columbia regarding prostate cancer care.

Grades were based on such areas as: Mortality and screening rates Support for prostate cancer-related legislation

Alabama was one of five states that received an “F” grade.

Alabama’s Prostate Cancer Report Card

National Prostate Cancer Coalition. First-Ever Prostate Cancer Report Cards Released. Press release dated May 22, 2006.

Despite the unfavorable grade, this report brought much needed attention to the disparities and deficiencies that exist in prostate cancer care in Alabama, and served as a catalyst for change.

Alabama’s Prostate Cancer Report Card

Alabama has the third highest death rate due to prostate cancer in the nation.

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PROSTATE CANCER MORTALITY RATES: U.S./STATE, 2007-2009

Centers for Disease Control and Prevention. National Center for Health Statistics. Health Data Interactive. www.cdc.gov/nchs/hdi.htm. Accessed May 16, 2012. Rates are three-year annual averages of the number of deaths per 100,000 population and are age-adjusted to the U.S. standard population in 2000.

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U.S.

Alabama v. Other States

Centers for Disease Control and Prevention. National Center for Health Statistics. Health Data Interactive. www.cdc.gov/nchs/hdi.htm. Accessed May 16, 2012. Rates are three-year annual averages of the number of deaths per 100,000 population and are age-adjusted to the U.S. standard population in 2000.

For African-American men, Alabama has the highest death rate due to prostate cancer in the nation.

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PROSTATE CANCER MORTALITY RATES: U.S./STATE, 2007-2009

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Alabama v. Other States

Alabama Statewide Cancer Registry. Rates are per 100,000 and age-adjusted to the 2000 U.S. (19 age groups) standard.

Prostate Cancer Incidence and Mortality Rates for Alabama, 2000-2009

Alabama Statistics by Race

African-Americans in Alabama therefore have:

a prostate cancer incidence rate that is 1.8 times that of Caucasions in the State

a prostate cancer mortality rate that is 3.1 times that of Caucasions in the State

Alabama Statistics by Race

African-Americans tend to have more aggressive cancers at the time of diagnosis, which may contribute to the disparity in mortality rates.

They are also less likely to be screened for prostate cancer. National Health Interview Survey found that use of

PSA to test for prostate cancer was lower in African-American males, compared to white males aged 50 and older (38.6% vs. 46.6%, respectively).

Other Observed Differences

Wu I, Modlin CS. Disparities in prostate cancer in African American men: What primary care physicians can do. Cleve Clin J Med. 2012 May;79(5):314; American Cancer Society. Cancer Facts & Figures for African Americans 2011-2012. Atlanta: American Cancer Society, 2011, pp. 18-19.

Research has shown that there are barriers to screening for prostate cancer and the timely diagnosis of this disease. These barriers make African-Americans less likely

to receive regular physical exams and screening for prostate cancer.

Barriers to screening include: low socioeconomic status, lack of health insurance coverage, unequal access to healthcare services, and absence of ties to a PCP.

National Cancer Institute. Cancer Health Disparities FactSheet (2008).

Possible Causes forRacial Disparities

Recent research also suggests that genetic factors might account, in part, for observed differences in incidence. Researchers have identified variants in human DNA

that are associated with the risk of developing prostate cancer.

Nearly all of the variants associated with an increased risk of developing prostate cancer were found most often in African-American men.

National Cancer Institute. Cancer Health Disparities FactSheet (2008).

Possible Causes forRacial Disparities

Alabama Counties With

Prostate Cancer Mortality

Rates Greater Than

The State Average (highlighted in blue)

Alabama Statewide Cancer Registry. Rates are per 100,000 and age-adjusted to the 2000 U.S. (19 age groups) standard. Data covers 2000-2009 time period.

Geographic Disparities

Legislation

Screenings of At-Risk Populations

Public and Provider Education

Initiatives That Seek ToReduce These Disparities

Ashvin Parikh of the Alabama Department of Public Health shown here at the free prostate cancer screening held in Sumter County, Alabama on April 2, 2011. A total of 168 men were screened for prostate cancer that day.

Legislative Actions Knowing that there was zero funding in the

Alabama State budget for prostate cancer screening in the State compared to over $400,000 for breast cancer, Urology Centers of Alabama vigorously lobbied and secured $100,000 for these screenings.

Urology Centers of Alabama also helped to get a state law passed that requires insurance companies in Alabama to cover physician-ordered prostate cancer tests.

ADPH Collaborations Alabama Department of Public Health has

partnered with the Urology Health Foundation and other organizations to offer free prostate cancer screenings to men aged 40-75 in various counties throughout the State.

Started by Urology Centers of Alabama physicians in 2003

UHF’s purposes were expanded in 2006 to include free urological screenings.

Since 2007, UHF/UCA have screened over 4,000 men for prostate cancer--many from the Black Belt Region of the State.

UHF has held free prostate cancer screenings in 18 Alabama counties over the 2007-2012 period.

Urology Health Foundation

UHF’s Screenings by Number of Counties

UHF’s Screeningsby Number of Men Screened

Aspects of UHF’s Screenings

Advance trips Trips made to

screening locations to meet with ADPH officials, community leaders, PCP’s, and media

Advance trip made on 10-19-10 before UHF's free prostate cancer screening in Conecuh County Publicity

Notices sent to churches, media, County Extension Offices, Chambers of Commerce, PCP’s, businesses, and prior participants

Website and social media postings

Aspects of UHF’s Screenings

Day of screening Examining

physicians with urological expertise travel to the counties involved

Information obtained on family history, age, race, and prostate medications

PSA test and DRE performed Drs. Moody and Sanfelippo, Wilcox County screening, 10-16-10

Aspects of UHF’s Screenings

Review of screening results and follow-up

Results are reviewed by a urologist.

UHF notifies the screening participants of the results and the urologist’s recommendations.

If an abnormality is found and the patient is unable to afford treatment, UHF will assist in helping to find treatment at no cost to the patient.

Public Education

Public Education

“Create a Buzz about Blue” campaign

A joint effort by Alabama Comprehensive Cancer Control Coalition Prostate Services and Alabama Cooperative Extension System

Provides a variety of educational opportunities (known as “The Blue Seminars”) at the community level

Goals are to educate men and women in their lives about prostate health, importance of early detection, and effectiveness of treatments

Provider Education

Primary care physicians are often the first point of healthcare access and play a key role in educating and screening their patients.

Dr. Carl Sanfelippo speaks on prostate cancer at Urology Centers of Alabama’s “Primary Care and Common Urinary Problems” CME seminar on 2-21-09.

Continuing Medical Education is an important means of filling in PCP “knowledge gaps.”

Future Challenges

Future Challenges

Funding levels for prostate cancer research, education, and screenings

Access to specialists

U.S. Preventive Services Task Force (USPSTF) recommendation against PSA testing

Patient Protection and Affordable Care Act

At the State level, prostate cancer receives about 1/4 the funding that breast cancer receives. The high point in funding for prostate cancer was

$100,000, but in the last three years funds have been reduced due to proration.

Similar funding disparities exist at the Federal level and also in private grants.

State Funding

Federal FundingBreast Cancer v. Prostate Cancer

Medical Research from NIH

ZERO – The Project to End Prostate Cancer. All numbers represented in this chart are in millions. Figures for 2011 and 2012 are approximate.

Federal FundingBreast Cancer v. Prostate Cancer

Medical Research Funding at Department of Defense

ZERO – The Project to End Prostate Cancer. All numbers represented in this chart are in millions.

Private Grants

American Cancer Society Current Grants by Cancer Type as of 3/1/12

American Cancer Society. http://bit.ly/vTPjE4. Accessed May 25, 2012.

Access to Specialists

Geographic distribution of urologists:

Overall 63% of counties in the United States lack a urologist.

Urologists younger than 45 years old are 3 times less likely to be located in nonmetropolitan and rural counties than their older counterparts.

Odisho AY, Fradet V, Cooperberg MR, Ahmad AE, Carroll PR. Geographic distribution of urologists throughout the United States using a county level approach. J Urol. 2009 Feb;181(2):760-5.

Access to Specialists

What impact will this uneven distribution of urologists have on prostate cancer care? One study examined the effect of increasing

urologist density on local prostate, bladder, and kidney cancer mortality.

Using regression models, it found that for each of the three cancers, there was a statistically significant cancer-specific mortality reduction associated with counties that had more than zero urologists (16% to 22% reduction for prostate cancer).

Odisho AY, Cooperberg MR, Fradet V, Ahmad AE, Carroll PR. Urologist density and county-level urologic cancer mortality. J Clin Oncol. 2010 May 20;28(15): 2499-504.

USPSTF Recommendation In May 2012, the USPSTF released its final

recommendation against PSA-based screening for prostate cancer.

Many urologists, prostate cancer patients, and patient advocacy groups disagree with the Task Force’s analysis and recommendation.

One of the concerns is that this “one size fits all” approach will have a discouraging effect, especially on at-risk populations.

USPSTF Recommendation

For example, the American Urological Association has stated that:

“It is inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations, such as African American men. Men who are in good health and have more than a 10-15 year life expectancy should have the choice to be tested and not discouraged from doing so.”

-- American Urological Association press release dated May 21, 2012.

Bureaucratic approach is to: issue “one size fits all” for large classes of people ration vs. empowering patient and doctor to make

best decisions for individuals NIH and NCI should have been advised to

search for better screening test and encourage conservative treatment for low-risk dz.

Lethal bureaucracy is a disease that is

Death by Bureaucracyby Newt Gingrich

treatable with the right policies.

The status and impact of this legislation are uncertain at this time.

Patient Protection and Affordable Care Act

Dr. Scott Tully of Urology Centers of Alabama waves as he rides in the Tour de Blue: Cycling for Prostate Cancer Awareness event.

Thank You!

Thomas E. Moody, M.D. (205) 930-0920

Disparities in

Prostate Cancer Care:

The Alabama Experience