Population Density and Facility Type Influence Management of Prostate Cancer

Abstract

Men with localized prostate cancer have several conventional management options. Which option a patient chooses is likely influenced by multiple factors. In this study, we investigated the role of population density and facility types on first course treatment for men with localized prostate cancer in the United States. Using the National Cancer Database, we identified men who were diagnosed with localized prostate cancer from 2004-2015. The U.S. was divided into three groups based on codification of population size and urbanization by the United States Department of Agriculture Economic Research Service: metropolitan, urban, and rural. To assess facility type influences, facilities were classified by the Commission on Cancer Accreditation program based on structural characteristics. Due to structural similarities, Community Cancer Programs, Comprehensive Community Cancer Programs, and Integrated Network Cancer Programs were combined to form Community Cancer Centers (CCC) and were compared to a second group, Academic/Research Programs (ARP). Treatment was recorded as either external-beam radiotherapy (RT), radical prostatectomy (RP) or active surveillance (AS). The RT group contained patients receiving external beam or brachytherapy, or RT plus androgen deprivation therapy (ADT). The RP group included patients receiving either RP or RP combined with RT or ADT, since surgery was the primary treatment recommendation. Two Chi-Square tests were used with significance level of 1% to assess the associations between both facility type and urban/rural counties and frequency of RT, AS and RP. All analyses and summaries were performed using data and decision management software. This study identified 1,277,411 men with prostate cancer treated in the U.S., of whom 57.32% underwent RP, 40.11% underwent RT, and 2.05% chose AS. The utilization of RT varied significantly (p=<0.0001) in urban versus rural settings. In urban counties, RT was utilized primarily in 48.40% of patients, while in rural counties was utilized less frequently (38.01%) (p=<0.0001). RP utilization varied similarly. AS usage patterns did not vary by population density. In addition, utilization varied based on facility type (p=<0.0001), indicating a higher frequency of RT (43.20%) at CCC than at ARP (32.40%). There was a significant difference (p=<0.0001) between the frequency of RP at CCC (55.00%) compared to ARP (63.63%). Lastly, there was a significant difference (p=<0.0001) in the frequency of AS occurring at ARP (3.97%) than at CCC (1.80%). Population density and facility type differences exist in the U.S. regarding initial management for localized prostate cancer. The reasons for these differences are likely complex, involving physician and patient preference, differences in training and resource access.