Equal Access Health Care System Research Articles

Racial disparities in stage at bladder cancer diagnosis in the US Veterans Affairs healthcare system.

To describe patient characteristics and pathological stage at bladder cancer (BCa) diagnosis in a diverse population within a national, equal-access healthcare system. This retrospective cohort study identified 15 966 men diagnosed with BCa in the Veterans Affairs (VA) healthcare system from 2000 to 2020. The primary outcome was pathological stage at diagnosis, determined by index transurethral resection of bladder tumour. Logistic regression was used to assess the relationship between race and stage. Competing risk models tested the association between race and BCa-specific mortality with cumulative incidence estimates. Of 15 966 BCa patients, 12 868 (81%), 1726 (11%), 493 (3%) and 879 (6%) were White, Black, Hispanic and Other race, respectively. Black patients had significantly higher muscle-invasive bladder cancer (MIBC) rates than White patients (35% vs 32%; P = 0.009). In multivariable analysis, the odds of presenting with MIBC did not differ significantly between Black and White patients (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.98-1.22) or between Hispanic patients (OR 0.82, 95% CI 0.67-1.01) and White patients. Compared to White patients, Black patients had a similar risk of BCa-specific mortality (hazard ratio [HR] 0.89, 95% CI 0.75-1.06), whereas Hispanic patients had a lower risk (HR 0.56, 95% CI 0.38-0.82). Black patients presented with the highest rates of de novo MIBC. However, in a large, equal-access healthcare system, this did not result in a difference in BCa-specific mortality. In contrast, Hispanic patients had lower risks of MIBC and BCa-specific mortality.

Survival Outcomes by Race and Ethnicity in Veterans With Nonmetastatic Castration-Resistant Prostate Cancer

Racial and ethnic disparities in prostate cancer are poorly understood. A given disparity-related factor may affect outcomes differently at each point along the highly variable trajectory of the disease. To examine clinical outcomes by race and ethnicity in patients with nonmetastatic castration-resistant prostate cancer (nmCRPC) within the US Veterans Health Administration. A retrospective, observational cohort study using electronic health care records (January 1, 2006, to December 31, 2021) in a nationwide equal-access health care system was conducted. Mean (SD) follow-up time was 4.3 (3.3) years. Patients included in the analysis were diagnosed with prostate cancer from January 1, 2006, to December 30, 2020, that progressed to nmCRPC defined by (1) increasing prostate-specific antigen levels, (2) ongoing androgen deprivation, and (3) no evidence of metastatic disease. Patients with metastatic disease or death within the landmark period (3 months after the first nmCRPC evidence) were excluded. The primary outcome was time from the landmark period to death or metastasis; the secondary outcome was overall survival. A multivariate Cox proportional hazards model, Kaplan-Meier estimates, and adjusted survival curves were used to evaluate outcome differences by race and ethnicity. Of 12 992 patients in the cohort, 826 patients identified as Hispanic (6%), 3671 as non-Hispanic Black (28%; henceforth Black), 7323 as non-Hispanic White (56%; henceforth White), and 1172 of other race and ethnicity (9%; henceforth other, including American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, unknown by patient, and patient declined to answer). Median time elapsed from nmCRPC to metastasis or death was 5.96 (95% CI, 5.58-6.34) years for Black patients, 5.62 (95% CI, 5.11-6.67) years for Hispanic patients, 4.11 (95% CI, 3.96-4.25) years for White patients, and 3.59 (95% CI, 3.23-3.97) years for other patients. Median unadjusted overall survival was 6.26 (95% CI, 6.03-6.46) years among all patients, 8.36 (95% CI, 8.0-8.8) years for Black patients, 8.56 (95% CI, 7.3-9.7) years for Hispanic patients, 5.48 (95% CI, 5.2-5.7) years for White patients, and 4.48 (95% CI, 4.1-5.0) years for other patients. The findings of this cohort study of patients with nmCRPC suggest that differences in outcomes by race and ethnicity exist; in addition, Black and Hispanic men may have considerably improved outcomes when treated in an equal-access setting.

Treatment and survival of de novo metastatic hormone sensitive prostate cancer among African American US Veterans.

5079 Background: Combinations of androgen deprivation therapy (ADT) plus docetaxel (DOC) or androgen signaling inhibitors (ASIs: abiraterone, enzalutamide, etc.) have revolutionized treatment of metastatic hormone sensitive prostate cancer (mHSPC), particularly for high volume disease. However, little is known about the use of and outcomes of combination therapy in African Americans (AA) with de novo mHSPC, due to their lack of representation in clinical studies. This study evaluates the patient characteristics, treatment, and survival in a cohort of US veterans with mHSPC with equal access to treatment under the Veterans Affairs Health System (VA). Methods: Veterans with mHSPC were identified from 2014-2022 in the VA using the initial pathological diagnosis of prostate cancer with SEER stage ‘distant’ and first ADT initiated within 1 month prior and 3 months after diagnosis. Therapies including DOC or ASIs were collected if initiated from 1 month prior to 4 months after ADT. Additional information at the time of diagnosis was collected including Prostate Specific Antigen (PSA), race from VA enrollment, and Charlson Comorbidity Index (CCI). Median survival was obtained for each group and stratified by PSA level >100 ng/mL. Chi-square and ANOVA testing were used differences in survival (OS) were assessed by log-rank testing. Results: 4,248 veterans with de novo mHSPC were identified, 1138 (26.8%) were AA and 3110 (73.2%) white. Black veterans were younger (70.8 vs. 74.8, p<0.001) and had higher median PSA (183 vs. 86.3, p<0.001) with similar mean CCI (4.4 vs. 4.4, p=0.78). AA veterans were likely to have a PSA >100 ng/mL at diagnosis (61.6% vs. 46.1%, p<0.001) and to receive combination therapy than white veterans (36.8% vs. 32.7%, p=0.01). The median OS among AA and white veterans was similar (32.5 months vs. 32.1, p=0.75). In 2,120 veterans with PSA>100 ng/mL (a surrogate for higher volume disease), AA veterans were more likely to receive combination therapy (39.5% vs. 32.9%, p=0.003) without differences in survival in AA veterans compared to white (31.0 vs. 26.9 months, p=0.18). Conclusions: In an equal access health care system, AA veterans had similar survival to white veterans despite having double the PSA levels, reflecting higher risk disease. AA presented 4 years younger and are likely treated with doublet therapy. The differences in the age of onset and burden of disease highlight persistent differences in populations with mHSPC. Further investigations to understand environmental, social, and tumor factors are warranted to explain these disparities. [Table: see text]

Time from biopsy to radical prostatectomy by race in an equal-access healthcare system: Results from the SEARCH cohort.

We previously showed that within an equal-access health system, race was not associated with the time between prostate cancer (PC) diagnosis and radical prostatectomy (RP). However, in the more recent time-period of the study (2003-2007), Black men had significantly longer times to RP. We sought to revisit the question in a larger study population with more contemporary patients. We hypothesized that time from diagnosis to treatment would not differ by race, even after accounting for active surveillance (AS) and the exclusion of men at very low to low risk of PC progression. We analyzed data from 5885 men undergoing RP from 1988 to 2017 at eight Veterans Affairs Hospitals from SEARCH. Multiple linear regression was used to compare time from biopsy to RP and to examine the risk of delays (>90 and >180 days) between races. In sensitivity analyses we excluded men deemed to have initially chosen AS based on having >365 days from biopsy to RP and men at very low to low PC risk for progression according to National Comprehensive Cancer Network Clinical Practice Guidelines. At biopsy, Black men (n = 1959) were younger, had lower body mass index, and higher prostate specific antigen levels, (all p < 0.02), compared to White men (n = 3926). Time from biopsy to RP was longer in Black men (mean days: 98 vs. 92; adjusted ratio of mean number of days, 1.07 [95% confidence interval: 1.03-1.11], p < 0.001); however, there were no differences in delays >90 or >180 days after adjusting for confounders (all p ≥ 0.286). Results were similar following the exclusion of men potentially under on AS and at very low and low risk. In an equal-access healthcare system, we did not find evidence of clinically relevant differences in time from biopsy to RP in Black versus White men.

Survival outcomes in Veterans with hepatocellular carcinoma, with and without HIV infection.

HIV infection has been associated with survival disparities among persons with hepatocellular carcinoma (HCC). However, most studies examining survival do not control for provider- (e.g. type of HCC treatment given) or individual-level factors (e.g. homelessness, substance use) that could impact survival. In this study, we evaluate the effect of HIV status on survival among persons with HCC, in a comprehensive model that accounts for key individual-, provider- and systems-level factors. We conducted a retrospective cohort study of people living with HIV (PLWH) matched 1:1 to HIV-uninfected controls based on age and year of HCC diagnosis in the national Veterans Administration (VA) health system. The primary outcome was survival. We used Cox regression models to evaluate the effect of HIV status on risk of death. This cohort included 200 matched pairs diagnosed with HCC between 2009-2016. A total of 114 PLWH (57.0%) and 115 HIV- patients (57.5%) received guideline-concordant therapy (P = 0.92). Median survival was 13.4 months (95% CI 8.7-18.1) among PLWH and 19.1 months (95% CI 14.6-24.9) for HIV-uninfected patients. In adjusted models, older age, homelessness, advanced Barcelona Clinic Liver Cancer (BCLC) stage, and not receiving any HCC treatment HCC predicted risk of death. HIV status was not associated with risk of death (aHR 0.95 [95% CI 0.75-1.20]; P = 0.65). HIV status was not associated with worse survival among HCC patients, in a single-payer, equal access health care system. These results suggest that HIV infection alone should not exclude PLWH from receiving standard therapy.

PD29-11 DISPARITIES IN STAGE AT DIAGNOSIS AMONG BLACK BLADDER CANCER PATIENTS IN THE LARGEST EQUAL ACCESS HEALTH SYSTEM IN THE US: THE VETERANS AFFAIRS HEALTH SYSTEM

You have accessJournal of UrologyCME1 Apr 2023PD29-11 DISPARITIES IN STAGE AT DIAGNOSIS AMONG BLACK BLADDER CANCER PATIENTS IN THE LARGEST EQUAL ACCESS HEALTH SYSTEM IN THE US: THE VETERANS AFFAIRS HEALTH SYSTEM Kelly Bree, Jessica Janes, Ruixin Yang, Patrick Hensley, Aditya Srinivasan, Amanda DeHoedt, Sanjay Das, Stephen Freedland, and Stephen Williams Kelly BreeKelly Bree More articles by this author , Jessica JanesJessica Janes More articles by this author , Ruixin YangRuixin Yang More articles by this author , Patrick HensleyPatrick Hensley More articles by this author , Aditya SrinivasanAditya Srinivasan More articles by this author , Amanda DeHoedtAmanda DeHoedt More articles by this author , Sanjay DasSanjay Das More articles by this author , Stephen FreedlandStephen Freedland More articles by this author , and Stephen WilliamsStephen Williams More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003315.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While Whites are more likely to be diagnosed with bladder cancer (BCa), Blacks are more commonly diagnosed with advanced stage and have increased risk of BCa-specific mortality (BCSM). The impact of many social determinants of health, including equal access to care, remain to be determined. We describe patient characteristics and pathologic stage at BCa diagnosis in a racially diverse population within a national, equal-access healthcare system. METHODS: This retrospective cohort study identified 16,585 men diagnosed with BCa in the US Department of Veterans Affairs (VA) from 2000-2020 who met inclusion criteria. Association between patient characteristics and race/ethnicity (Non-Hispanic White, Non-Hispanic Black, Hispanic, Other) were evaluated using chi-square and Kruskal-Wallis tests for categorical and continuous variables, respectively . The primary outcome was pathologic stage (NMIBC vs. MIBC) at diagnosis determined by natural language processing of initial diagnostic transurethral resection of bladder tumor. Multivariable competing risks regression tested the association between race and BCSM and the cumulative incidence of BCSM was calculated. RESULTS: Of 16,585 BCa patients, 13,086 (79%), 1,773 (11%), 534 (3%), and 1192 (7%) were White, Black, Hispanic, and Other race, respectively. Blacks were significantly more likely to be diagnosed with MIBC vs. Whites (35% vs. 32%, p=0.003). In multivariable analysis, race was also significantly associated with MIBC (p=0.023). Blacks were more likely to be diagnosed with MIBC than Whites (odds ratio [OR] 1.10, 95% CI 1.00-1.22), whereas Hispanics were less likely to have MIBC than Whites (OR 0.82, 95% CI 0.68-1.00). Race was also significantly associated with BCSM in multivariable analysis (p<0.001). Compared to Whites, BCSM was similar in Blacks (HR 1.03, 95% CI 0.88-1.22), while Hispanics had lower BCSM (HR 0.53, 95% CI 0.36-0.78). CONCLUSIONS: While Blacks were slightly more likely to present with de novo MIBC, in a large, equal-access healthcare system, this resulted in no increased risk of BCSM compared to Whites. In contrast, Hispanics had lower risk of MIBC and BCSM. Source of Funding: SBW: DOD Peer Reviewed Cancer Research Program Career Development Award (W81XWH1710576) . SD: PCORT UroGynCan (T32CA251072) © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e828 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kelly Bree More articles by this author Jessica Janes More articles by this author Ruixin Yang More articles by this author Patrick Hensley More articles by this author Aditya Srinivasan More articles by this author Amanda DeHoedt More articles by this author Sanjay Das More articles by this author Stephen Freedland More articles by this author Stephen Williams More articles by this author Expand All Advertisement PDF downloadLoading ...

MP77-02 HIGH AREA DEPRIVATION INDEX IS ASSOCIATED WITH DE NOVO PROSTATE CANCER METASTASIS IN VETERANS

You have accessJournal of UrologyCME1 Apr 2023MP77-02 HIGH AREA DEPRIVATION INDEX IS ASSOCIATED WITH DE NOVO PROSTATE CANCER METASTASIS IN VETERANS Ananta Wadhwa, Lorna Kwan, Michael Lewis, Brent Rose, Jennifer Cullen, Nicholas Nickols, Kara Maxwell, Kosj Yamoah, and Isla Garraway Ananta WadhwaAnanta Wadhwa More articles by this author , Lorna KwanLorna Kwan More articles by this author , Michael LewisMichael Lewis More articles by this author , Brent RoseBrent Rose More articles by this author , Jennifer CullenJennifer Cullen More articles by this author , Nicholas NickolsNicholas Nickols More articles by this author , Kara MaxwellKara Maxwell More articles by this author , Kosj YamoahKosj Yamoah More articles by this author , and Isla GarrawayIsla Garraway More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003351.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Metastatic prostate cancer (PCa) is highly lethal with a 5-year survival rate of 30%. Individuals with specific germline mutations, a family or personal cancer history, and/or identifying as Black/African-American display higher risk of developing PCa, including metastatic PCa. Healthcare barriers, such as lack of insurance and/or lower socioeconomic status, also correlate with advanced stage diagnosis. We sought to determine if the Area Deprivation Index (ADI), a ranking of socioeconomic disadvantage including income, education, employment, and housing quality, was associated with de novo metastases and/or metastatic progression in a racially/ethnically diverse VA PCa cohort. METHODS: Veterans diagnosed and/or treated for PCa from 2000-2013 in the Greater Los Angeles VA Healthcare System were identified in accordance with an institutional review board approved protocol. Clinical, pathological, and demographic data were obtained from the electronic medical record and the Veterans Health Administration Corporate Data Warehouse. State ADI (decile rank of 1-10) was calculated based upon the 9-digit residential zip code. Multivariate analyses identified factors associated with de novo metastasis or metastatic progression. Kaplan-Meier (KM) analysis permitted survival comparison of de novo metastatic (M1) cases, or localized cases with metastatic progression (M0-MP). RESULTS: Of 2152 PCa cases identified, ADI could be determined in 1498 (69.6%). There were 1311 M0, 76 M1, 136 MX cases, and 57 M0 patients who experienced metastatic progression (M0-P). On multivariate analysis, state ADI decile rank ≥7 was significantly associated with de novo metastasis diagnosis (rank 7-8: OR=4.39 (1.26, 15.35); rank 9-10: OR=4.12 (1.05, 16.09)). State ADI rank was not associated with metastatic progression in M0 patients. There were no significant differences in PCa-specific survival by ADI Rank within M1 nor M0-P strata. CONCLUSIONS: Veterans residing in areas of high socioeconomic disadvantage (ADI rank ≥7) were >4 times more likely to be diagnosed with de novo metastasis, while no effects of ADI were observed on PCa-survival in M1 cases or M0-P cases. These results suggest that even in a relatively equal access healthcare system, potential social barriers indicated by high ADI may lead to delayed diagnosis. Future studies linking frequency of healthcare visits and/or screening to ADI may reveal potential strategies to mitigate this disparity in the VA population. Source of Funding: Research support for the investigators include National Institutes of Health K08CA215312, KNM; 5P50CA092131, R01 PAR-20-077, IPG); US Department of Defense (W81XWH211075, IPG; W81XWH-19-1-0435, KY); Prostate Cancer Foundation (PCF17CHAL04, IPG; 20YOUNG02, KNM; 18VALO10, KY, NGN), Burroughs Wellcome Foundation (1017184, KNM); Basser Center for BRCA at the University of Pennsylvania (KNM); Jean Perkins Foundation (IPG), STOP Cancer Foundation (IPG), and VA ORD CSR&D (NGN) © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1101 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ananta Wadhwa More articles by this author Lorna Kwan More articles by this author Michael Lewis More articles by this author Brent Rose More articles by this author Jennifer Cullen More articles by this author Nicholas Nickols More articles by this author Kara Maxwell More articles by this author Kosj Yamoah More articles by this author Isla Garraway More articles by this author Expand All Advertisement PDF downloadLoading ...

Evaluation of disparities in impact of mental health intensive case management on 6-month symptoms, functioning, and quality of life between black and white veterans diagnosed with schizophrenia.

Substantial health disparities have been reported between Black and White Americans diagnosed with schizophrenia. The nature and extent of these disparities among individuals receiving services in an equal-access health care system remains understudied. The purpose of this study was to examine disparities in enrollment characteristics, service delivery and clinical outcomes between Black and White veterans diagnosed with schizophrenia who received care in the Veterans Health Administration (VHA), an equal-access health care system. National program evaluation data from the VHA Intensive Community Mental Health Recovery (ICMHR) program were used to evaluate disparities between 2436 Black and 3565 White veterans who enrolled between 1999 and 2013. Veterans and case managers completed measures of sociodemographic factors, clinical history, clinical characteristics, and justice system involvement at enrollment and six months. Chi square and ANOVAs were used to evaluate enrollment and service delivery differences. Six-month changes were evaluated using multiple regression controlling for potentially confounding baseline characteristics. Effect sizes were evaluated with Cohen's d. Results indicated differences between Black and White veterans in clinical history, justice system involvement, and clinical characteristics at enrollment. Minimal differences in service delivery were noted and longitudinal analyses revealed no significant differences between Black and White veterans on the majority of outcomes. Fewer racial disparities in service use and outcomes were observed in ICMHR than in standard non-VA clinic settings. This study demonstrates that disparities may emerge more strongly from systemic rather than individual-level differences.

Effect of equal access to care on prostate cancer progression in minority patients.

33 Background: Prostate cancer (PC) is an androgen-dependent disease that initially responds to androgen deprivation therapy (ADT); however, it can become resistant to therapies that reduce testosterone levels, signaling a transition to non-metastatic, castration-resistant PC (nmCRPC). Racial disparities are known in PC, with black and Hispanic men presenting with more advanced disease and having a higher mortality rate compared to non-Hispanic white men. The goal of treatment management in patients with nmCRPC is to prevent or delay metastases. This study examines the disease progression observed among patients with nmCRPC who received care and treatment in an equal access healthcare system, the Veterans Health Administration. Methods: Patient information was obtained from the Veterans Affairs (VA) Clinical Cancer Registry (VACCR) and the VA Corporate Data Warehouse (CDW) to identify patients who were diagnosed with prostate cancer at the VA and later developed nmCRPC, defined as (1) evidence of a rising prostate-specific antigen (PSA), i.e., 2 consecutive increases in PSA concentration over a baseline value; (2) evidence of ongoing androgen deprivation consisting of a serum testosterone level of ≤50 ng/dL (≤2.0 nmol/L); and (3) the absence of metastatic disease as evidenced in radiology reports. Treatments of nmCRPC were identified by review of NCCN Prostate Cancer Guidelines and extracted from CDW pharmacy dispensation records and indexed at nmCRPC diagnosis. A multivariate Cox proportional hazard model was used to identify time to metastatic disease in nmCRPC patients. Results: 654,148 patients were diagnosed with PC and received care in the VA from 2006 to 2021; of these, 12,992 developed nmCRPC, of whom 7,323 (56%) were white, 3,671 (28%) were black, 826 (6%) were Hispanic, and 1,172 (9%) were reported as other. Compared with white men at nmCRPC diagnosis, black men were younger (70 years vs. 74 years) while Hispanic men were older (75 years). White and Hispanic men had similar PSA at nmCRPC (10.2 ng/mL and 10.4 ng/mL), while the PSA for black men was higher (14.3 ng/mL). Similar treatment patterns were observed in all patients regardless of race; with ADT (60%), bicalutamide (24%), and finasteride (3%), the most frequently used first-line treatments. The mean time from nmCRPC to metastatic CRPC was 27.5 days for white men, 31.6 days for black men, 27.6 for Hispanic men, and 26.0 days for others. After adjusting for age, comorbidities, PSA doubling time, and treatment, the hazard ratio (HR) for developing metastatic disease was 0.85 (95% CI: 0.80–0.90, &lt;0.001) for black men, 0.70 (95% CI: 0.62–0.78, &lt;0.001) for Hispanic men, and 1.07 (95% CI: 0.99–1.16, &lt;0.001) for others. Conclusions: These results suggest that when provided with care and treatment in an equal access healthcare system, black and Hispanic patients with nmCRPC are less likely to progress to metastatic CRPC than non-Hispanic white men.

Metabolic syndrome is associated with aggressive prostate cancer regardless of race.

Recent meta-analyses suggest the Metabolic Syndrome (MS) increases high-grade prostate cancer (PC), although studies are inconsistent and few black men were included. We investigated MS and PC diagnosis in black and white men undergoing prostate biopsy in an equal access healthcare system. We hypothesized MS would be linked with aggressive PC, regardless of race. Among men undergoing prostate biopsy at the Durham Veterans Affairs Hospital, medical record data abstraction of diagnosis or treatment for hypertension (≥ 130/85mmHg), dyslipidemia (HDL < 40mg/dL), hypertriglyceridemia (≥ 150mg/dL), diabetes, hyperglycemia (fasting glucose ≥ 100ml/dL), and central obesity (waist circumference ≥ 40 inches) were done. Biopsy grade group (GG) was categorized as low (GG1) or high (GG2-5). Multinomial logistic regression was used to examine MS (3-5 components) vs. no MS (0-2 components) and diagnosis of high grade and low grade vs. no PC, adjusting for potential confounders. Interactions between race and MS were also tested. Of 1,051 men (57% black), 532 (51%) had MS. Men with MS were older, more likely to be non-black, and had a larger prostate volume (all p ≤ 0.011). On multivariable analysis, MS was associated with high-grade PC (OR = 1.73, 95% CI 1.21-2.48, p = 0.003), but not overall PC (OR = 1.17, 95% CI 0.88-1.57, p = 0.29) or low grade (OR = 0.87, 95% CI 0.62-1.21, p = 0.39). Results were similar in black and non-black men (all p-interactions > 0.25). Our data suggest that metabolic dysregulation advances an aggressive PC diagnosis in both black and non-black men. If confirmed, prevention of MS could reduce the risk of developing aggressive PC, including black men at higher risk of PC mortality.

Diagnosis and treatment patterns of Peyronie's disease among different racial, ethnic, and regional groups in the Veterans Affairs healthcare system.

Peyronie's Disease, which is known to have racial/ethnic disparities in the general population, has never been studied in the veteran population. We compared the diagnosis and treatment rates for Peyronie's Disease among United States veterans of various racial-ethnic backgrounds at Veterans Affairs medical centers, which are equal-access systems. We queried the Veterans Affair Informatics and Computing Infrastructure to identify 17,647 Peyronie's Disease patients in the United States by ICD-9 or ICD-10 code between 2015-2020. We assessed demographic characteristics, clinical characteristics, Veterans Affairs facility information, and treatment patterns. Racial-ethnic demographics of veterans with Peyronie's Disease were 71.4% White, 15.4% Black, 5.8% Hispanic, 1.6% Native American, 0.3% Asian, and 5.4% unknown. Treatment rate was 13.6% overall, 13.6% of Whites (ref), 14.3% of Blacks (p = 0.2985), 13.5% of Hispanics (p = 0.9205), 9.1% of Asians (p = 0.3319), 16.7% of Native Americans (p = 0.1406), and 9.6% of unknown (p = 0.0041). White patients were more likely to receive injectional therapy and less likely to undergo surgery than Black patients. Peyronie's Disease patients at Veterans Affairs facilities are treated at the same rate, indicating that equal-access healthcare systems may mitigate racial-ethnic disparities. Further research is necessary to account for differences in disease severity and Veterans Affairs surgeon availability.

Real-world treatment patterns among veterans with nonmetastatic castration-resistant prostate cancer (nmCRPC).

e17042 Background: Prostate cancer (PC) is the most common cancer diagnosed among U.S. Veterans. Non-metastatic castration-resistant prostate cancer (nmCRPC) occurs in patients who, despite having received androgen deprivation therapy, experience a rising prostate-specific antigen (PSA) and castrate testosterone levels, with no evidence of metastatic disease on radiographic imaging. Given the recent approval of novel antiandrogens, the treatment landscape for nmCRPC has rapidly evolved. Although there have been numerous clinical trials examining the safety and efficacy of these treatments, few studies have identified real-world treatment patterns among nmCRPC patients. Methods: We conducted a retrospective observational study using patient information obtained from the Veterans Affairs (VA) Clinical Cancer Registry and the VA Corporate Data Warehouse (CDW) to identify patients who were diagnosed with PC at the VA, and later developed nmCRPC, defined as having: (1) evidence of rising PSA, i.e., 2 consecutive increases in PSA concentration over a baseline value; (2) evidence of ongoing androgen deprivation consisting of a serum testosterone level of ≤50 ng/dL (≤2.0 nmol/L); and (3) no evidence of metastatic disease on radiology reports. Treatments were extracted from CDW pharmacy dispensation records and were indexed at nmCRPC diagnosis. Results: A total of 12,549 patients were diagnosed with nmCRPC and treated in the VA from 2006 to 2020; of these, 7,239 (58%) were white, 3,386 (27%) were black, 784 (6%) were Hispanic, and 1,140 (9%) other. Median age at PC diagnosis was 69 years, with most patients residing in the South 4,817 (38%). Of the 7,659 (61%) patients receiving first-line (1L) nmCRPC therapy, 5,508 (72%) received bicalutamide, 621 (8%) ketoconazole, 563 (7%) abiraterone, 492 (6%) enzalutamide, and 242 (3%) flutamide. Although bicalutamide remained the most frequently used 1L nmCRPC therapy regardless of year, the adoption of abiraterone and enzalutamide beginning in 2012 resulted in a decline of 1L bicalutamide from 80% of patients in 2006 to 43% in 2020. Ketoconazole was the second most common 1L nmCRPC therapy and the most common second-line (2L) and third line (3L) nmCRPC therapy. Of patients receiving 1L therapy, 2,244 (31%) received 2L therapy, and of these, 708 (32%) received 3L therapy. Conclusions: To our knowledge, this is the largest real-world cohort of nmCRPC patients treated in a nationwide equal-access health care system. Despite the recent approval of several nmCRPC treatments (apalutamide, darolutamide, enzalutamide) which have demonstrated improved metastasis-free survival and treatment-related quality of life, our real-world findings suggest that older, first-generation antiandrogens remain the predominant 1L treatment for nmCRPC patients.

Lifestyle and sociodemographic factors associated with treatment choice of clinically localized prostate cancer in an equal access healthcare system.

Sociodemographic and lifestyle factors may play a role in determining whether patients with clinically localized prostate cancer (PC) are managed with active surveillance (AS), radical prostatectomy (RP), or radiation therapy (RT); however, these relationships have not been well examined. In a cross-sectional study conducted within an equal access healthcare system, multivariable adjusted regression analysis revealed that living with a spouse or partner was associated with a 65% lower chance of being managed by RT (P = 0.001) and 57% lower risk of being managed by AS (P = 0.042) compared with RP. No other sociodemographic or lifestyle factors were independently associated with treatment modality.

Abstract P3-14-04: Genetic testing in non-Hispanic Black women with breast cancer treated within an equal-access healthcare system

Abstract Purpose: Identification of women with hereditary forms of cancer allows for use of precision medicine approaches to improve survival. Non-Hispanic Black (NHB) women in the US general population are less likely to undergo genetic testing or utilize risk-reducing strategies. Whether these disparities exist within the equal-access military healthcare system of the Department of Defense is not known. Methods: Genetic test information and surgical procedures were extracted for all NHB and Non-Hispanic Whites (NHW) with invasive breast cancer who were diagnosed and treated at the Murtha Cancer Center at Walter Reed National Military Medical Center and enrolled in the Clinical Breast Care Project. National Comprehensive Cancer Network criteria from the year of diagnosis were assessed for all patients. Data were analyzed using chi-square analysis with p&amp;lt;0.05 defining significance. Results: NHB were significantly (p=0.009) more likely to meet criteria for genetic testing compared to NHW, however, test uptake did not differ significantly between populations (p=0.292). Pathogenic variant frequency (p=0.597), prophylactic mastectomy (p=0.915) and oophorectomy (p=0.076) did not differ significantly between populations. Conclusion: These data demonstrate that when barriers, such as cost and lack of insurance barriers were removed, NHB were as willing to pursue testing and risk-reducing strategies as their NHW counterparts. Increasing the availability of testing and clinical management for NHB with hereditary forms of cancer may help reduce disparate survival seen in the US general population. The contents of this publication are the sole responsibility of the author(s) and do not necessarily reflect the views, opinions or policies of Uniformed Services University of the Health Sciences (USUHS), The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the Department of Defense (DoD) or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government. Citation Format: Rachel Ellsworth, Ashlee Vargason, Clesson Turner, Craig Shriver. Genetic testing in non-Hispanic Black women with breast cancer treated within an equal-access healthcare system [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-14-04.

Socioeconomic Disparities in Pancreas Cancer Resection and Survival in the Veterans Health Administration.

Disparities based on socioeconomic factors such as race, ethnicity, marital status, and insurance status are associated with pancreatic cancer resection, but these disparities are usually not observed for survival after resection. It is unknown if there are disparities when patients undergo their treatment in a non-fee-for-service, equal-access healthcare system such as the Veterans Health Administration (VHA). Patients having T1-T3 M0 pancreatic adenocarcinoma diagnosed between 2006 and 2017 were identified from the VHA Corporate Data Warehouse. Socioeconomic, demographic, and tumor variables associated with resection and survival were assessed. In total, 2580 patients with early-stage pancreatic cancer were identified. The resection rate was 36.5%. Surgical resection was independently associated with younger age [odds ratio (OR) 0.94, p<0.001], White race (OR 1.35, p=0.028), married status (OR 1.85, p=0.001), and employment status (retired vs. unemployed, OR 1.41, p=0.008). There were no independent associations with Hispanic ethnicity, geographic region, or Social Deprivation Index. Resection was associated with significantly improved survival (median 21 vs. 8 months, p=0.001). Among resected patients, survival was independently associated with younger age (HR 1.019, p=0.002), geographic region (South vs. Pacific West, HR 0.721, p=0.005), and employment (employed vs. unemployed, HR 0.752, p=0.029). Race, Hispanic ethnicity, marital status, and Social Deprivation Index were not independently associated with survival after resection. Race, marital status, and employment status are independently associated with resection of pancreatic cancer in the VHA, whereas geographic region and employment status are independently associated with survival after resection. Further studies are warranted to determine the basis for these inequities.

Genetic testing in Non-Hispanic Black women with breast cancer treated within an equal-access healthcare system

PurposeIdentification of women with hereditary forms of cancer allows for precision medicine approaches to improve survival. Non-Hispanic Black (NHB) women in the US general population are less likely to undergo genetic testing or utilize risk-reducing strategies. Whether these disparities exist within the equal-access US military healthcare system is not known. MethodsGenetic test information and surgical procedures were extracted for all NHB and Non-Hispanic Whites (NHW) with invasive breast cancer. National Comprehensive Cancer Network criteria from the year of diagnosis were assessed for all patients. Data were analyzed using chi-square analysis with P < .05 defining significance. ResultsNHB were significantly (P = .009) more likely to meet criteria for genetic testing compared to NHW, however, test uptake did not differ significantly between populations (P = .292). While 81% of both populations with BRCA1/2 pathogenic variants elected for double mastectomy, NHW were two times more likely to undergo risk-reducing bilateral salpingo-oophorectomy. ConclusionThese data demonstrate that when barriers, such as cost and lack of insurance, were removed, NHB were as willing to pursue testing as their NHW counterparts. Increasing the availability of testing and clinical management for NHB with hereditary forms of cancer may help reduce disparate survival seen in the US general population.

With Equal-Access, Service Members with Lymphoma Have Better Outcomes Than Their Civilian Counterparts

Introduction: The Military Health System (MHS) is a single-payer, equal-access healthcare system that provides healthcare to 1.4 million active-duty service members (ADSMs) from diverse socioeconomic backgrounds. ADSMs with cancer receive prompt care without copayments, deductibles, prior authorizations, or other insurance barriers. Lymphoma is the most common hematologic malignancy diagnosed in ADSMs. We sought to compare overall survival (OS) of ADSMs with lymphoma with matched civilian lymphoma patients. We also sought to identify variables among ADSMs that predicted OS.Methods: The Department of Defense Automated Central Tumor Registry (ACTUR) was retrospectively accessed to identify ADSMs with Hodgkin Lymphoma (HL), diffuse large B-cell lymphoma (DLBCL), and indolent lymphomas over a 20-year span from 1997-2017. A comparator arm was created from the National Cancer Institute's Surveillance, Epidemiology and End-Result (SEER)-18 database and was matched in a 4:1 ratio by age, sex, race, ethnicity, year of diagnosis, and stage. OS was assessed with Cox proportional hazards models. Kaplan Meier curves were constructed and compared using log rank tests. Among ADSMs, univariate and multivariable analyses were performed to assess OS based on race, ethnicity, sex, age at diagnosis, stage, year of diagnosis, rank, branch of service, and geographic region at diagnosis. All data analyses were conducted using STATA/SE 15.1 for Windows; the alpha level for statistical significance was set to 0.05.Results: There were 1,170 ADSMs with HL, 443 with DLBCL, and 284 with indolent lymphomas identified from ACTUR. Most ADSMs were between ages 20-40, white/non-Hispanic, enlisted, and in the Army. All three groups of ADSMs had superior OS when compared with their matched civilian counterparts. There were 49%, 48%, and 35% reductions in the risk of death among ADSMs with DLBCL, indolent lymphoma and Hodgkin lymphoma, respectively (DLBCL hazard ratio [HR] 0.51, 95% CI 0.40-0.65, p<0.0001; indolent HR 0.52, 95% CI 0.33-0.81, p <0.002; HL HR 0.65, 95% CI 0.52-0.82, p <0.002). Among the ADSMs, variables that reached statistical significance in the univariate and/or the multivariable analyses for OS include increasing age (DLBCL, indolent), advanced stage (DLBCL, HL), and geographic residence at diagnosis (DLBCL, HL). Notably, there were no statistically significant differences in OS based on race, ethnicity, sex, rank, or branch of service.Discussion: ADSMs with lymphoma treated within the MHS have significantly better survival than their matched civilian counterparts. Further, disparities based on race/ethnicity and sex are not present in the MHS, despite being pervasive in the civilian sector. It is possible that better access to care within the equal-access MHS might explain our results. Alternatively, regular fitness tests and periodic health assessments may render ADSMs are more fit and less comorbid than their civilian counterparts, translating to a better chance of long-term survival. Although this study is limited by its retrospective design and possible coding inaccuracies, the finding of advanced age and stage impacting OS serves as a good internal control and confirms the quality of ACTUR data. Findings from this study reflect favorably on ADSMs with cancer. The absence of racial/ethnic or gender disparities reflects favorably on cancer care received within the equal-access MHS. [Display omitted] DisclosuresThornton: Undisclosed Companies: Current equity holder in publicly-traded company.

Inequality in place-of-death among children: a Danish nationwide study.

To identify predictors for home death among children using socio-demographic factors and cause of death. It is a nationwide registry study. A cohort of children (1-17years) who died between 1 January 2006 and 31 December 2016. It was set in Denmark, Europe. Predictors for home death were assessed: age, gender, diagnosis, region of residence, urbanicity, household income and immigrant status. Of 938 deceased children included, causes of death were solid tumours (17.3%), haematological cancers (8.5%) and non-cancerous conditions (74.2%). A total of 25% died at home. Compared to the lowest quartile, the groups with higher household income did not have a higher probability of dying at home (adjusted odds ratio (adj-OR) 0.8 (95% CI 0.5-1.2/1.3)). Dying of haematological cancers (adj-OR 0.3 (95% CI 0.2-0.7)) and non-cancerous conditions (adj-OR 0.5 (95% CI 0.3-0.7)) was associated with lower odds for home death compared to dying of solid tumours. However, being an immigrant was negatively associated with home death (adj-OR 0.6 (95% CI 0.4-0.9)). Moreover, a tendency was also found that being older, male, living outside the capital and in more urban areas were notable in relation to home death, however, not statistically significant.Conclusions: The fact that household income was not associated with dying at home may be explained by the Danish tax-financed healthcare system. However, having haematological cancers, non-cancerous conditions or being an immigrant were associated with lower odds for home death. Cultural differences along with heterogeneous trajectories may partly explain these differences, which should be considered prospectively. What is Known: • Prior studies have shown disparities in place-of-death of terminally ill children with diagnosis, ethnicity and socio-economic position as key factors. • Danish healthcare is tax-financed and in principle access to healthcare is equal; however, disparities have been found in the intensity of treatment of terminally ill children. What is New: • In a tax-financed, equal-access healthcare system, children died just as frequently at home in families with low as high household income. • Disparities in home death were related to diagnosis and immigrant status.

MP11-15 REAL-WORLD EVIDENCE OF 18F-FLUCICLOVINE PET/CT UTILIZATION FOR RECURRENT PROSTATE CANCER IN THE VETERAN AFFAIRS HEALTH SYSTEM

You have accessJournal of UrologyProstate Cancer: Staging (MP11)1 Sep 2021MP11-15 REAL-WORLD EVIDENCE OF 18F-FLUCICLOVINE PET/CT UTILIZATION FOR RECURRENT PROSTATE CANCER IN THE VETERAN AFFAIRS HEALTH SYSTEM Zachary Klaassen, Lin Gu, Justin D. Waller, Amanda De Hoedt, Nancy Tainer, Jonathan Kinscherff, and Stephen J. Freedland Zachary KlaassenZachary Klaassen More articles by this author , Lin GuLin Gu More articles by this author , Justin D. WallerJustin D. Waller More articles by this author , Amanda De HoedtAmanda De Hoedt More articles by this author , Nancy TainerNancy Tainer More articles by this author , Jonathan KinscherffJonathan Kinscherff More articles by this author , and Stephen J. FreedlandStephen J. Freedland More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001984.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: 18F-Fluciclovine PET/CT was approved for use in 2016 for detection of biochemically recurrent prostate cancer (PC) after primary therapy. To date, there have been no population-level studies assessing utilization of 18F-fluciclovine PET/CT. The objective of this study was to assess utilization of 18F-fluciclovine PET/CT for recurrent PC in the Veterans Affairs (VA) Health System, focusing on sociodemographics, and the impact of PSA levels and use of androgen deprivation therapy (ADT) on 18F-fluciclovine PET/CT positivity rates. METHODS: There were 830 patients (pts) that received a 18F-fluciclovine PET/CT in the VA. A random selection of 300 pts from 44 sites were included, stratified by receipt of ADT and PSA (low <1 ng/mL vs high ≥1 ng/mL) at the time of imaging. The primary outcome was the result of 18F-fluciclovine PET/CT, categorized as positive vs negative vs equivocal. Comparison between these groups included the Kruskal-Wallis test for continuous variables and Chi-square or Fisher’s exact test for categorical variables. Logistic regression, adjusting for demographic and disease characteristics, was used to test the association between PSA, use of ADT, and race with 18F-fluciclovine PET/CT positive imaging. RESULTS: 18F-fluciclovine PET/CT positivity rate was 33% for pts with a PSA between 0-0.5 ng/mL, 21% for >0.5-1.0, 54% for >1.0-2.0, and 66% for >2.0 (p<0.0001). Pts currently treated with ADT had a positivity rate of 59% compared to 37% for those not treated with ADT (p=0.0004). There were too few pts that started ADT within 1 (n=10) and 3 months (n=17) to perform additional analyses assessing the impact of recently starting ADT. White pts were more likely to have a positive scan compared to black (55% vs 38%; p=0.02). Pts whose primary treatment was radical prostatectomy had a lower positivity rate (33%) compared to those treated with radiotherapy (55%; p<0.0001). There was no difference in positivity rate based on PET/CT manufacturer (p=0.70). Multivariable logistic regression showed that PSA (>1 vs ≤1 ng/mL; OR 3.47, 95% CI 1.65-7.29), use of ADT (yes vs no; OR 4.34, 95% CI 1.33-14.15), and race (black vs white; OR 0.50, 95% CI 0.25-0.99) were predictive of positive 18F-fluciclovine PET/CT. CONCLUSIONS: This real-world study assessing utilization of 18F-fluciclovine PET/CT in an equal access health-care system confirms the impact of PSA level on scan positivity rate. Additionally, pts currently receiving ADT have a >4x higher likelihood of a positive scan, showing that scan positivity was not negatively affected by ADT status. Source of Funding: Blue Earth Diagnostics, Inc © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e185-e185 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Zachary Klaassen More articles by this author Lin Gu More articles by this author Justin D. Waller More articles by this author Amanda De Hoedt More articles by this author Nancy Tainer More articles by this author Jonathan Kinscherff More articles by this author Stephen J. Freedland More articles by this author Expand All Advertisement Loading ...

Racial disparities in survival among women with endometrial cancer in an equal access system

ObjectiveThe mortality rate for Black women with endometrial cancer (EC) is double that of White women, although the incidence rate is lower among Black women. Unequal access to care may contribute to this racial disparity. This study aimed to assess whether survival varied between non-Hispanic Black (NHB) and non-Hispanic White (NHW) women with EC in the Military Health System (MHS) which provides equal access care to its beneficiaries despite racial/ethnic background. MethodsThe study was conducted using data from the U.S. Department of Defense's (DoD) Automated Central Tumor Registry (ACTUR). Study subjects included NHB and NHW women with histologically confirmed and surgically managed EC diagnosed between 1988 and 2013. The study outcome was all-cause death. Overall survival between NHB and NHW women was compared using multivariable Cox modeling. ResultsThe study included 144 NHB and 1439 NHW women with EC. Kaplan-Meier curves showed NHB women had worse survival than NHW women (log-rank P < 0.0001). The disparity in survival between NHB and NHW women persisted after adjusting for age, diagnosis period, tumor stage, tumor histology/grade, and adjuvant treatment (HR = 1.64, 95% CI = 1.19 to 2.27). Multivariable analyses stratified by tumor features or treatment showed that the racial disparity was confined to women with low-risk features (stage I/II disease or low-grade EC) or no adjuvant treatment. ConclusionThere were racial differences in overall survival between NHB and NHW women with EC in the MHS equal access healthcare system, suggesting that factors other than access to care may be related to this racial disparity.