The Reverend Jesse Jackson described the American dream as one big tent: “And on that big tent you have four basic promises: equal protection under the law, equal opportunity, equal access, and fair share.” A new study suggests that when it comes to prostate cancer (PCa), patients do not have equal access to medical care. Despite the national trend toward less invasive technologies, “treatment trends for localized prostate cancer differ by U.S. region, by state, and even from county to county.”[i] In fact, a man’s medical insurance can play a big role in which treatment he is likely to receive, as the study discovered different treatment PCa patterns between Medicare and private health insurance.
The study is partially an outcome of the NIDDK’s (National Institute of Diabetes and Digestive and Kidney Diseases) Urologic Diseases in America Project. It is based in Medicare data on over 77,000 men (diagnosed with PCa from 1993-2006) plus 63,000 patients (diagnosed from 2002-06) in a private insurance claims data base, for a total of over 140,000 cases. According to findings, here are some of the differences between the care patients receive based on their coverage:
|Percent of prostatectomies||12% rate stable over time||Increase from 33% in 2002 to 48% by 2006|
|Most common first method of treatment (2002)||Radiation therapy followed by hormone therapy||Prostatectomy|
|Active surveillance||9% put on AS as initial strategy||14% put on AS as initial strategy|
|Patient age at diagnosis||Tend to be older||Tend to be younger|
|Change in rates of laparoscopic prostatectomy||From 3% (2002) to 35% (2006)||From 1% (2002) to 41% (2006)|
Regarding the age difference, it is tempting to conclude that since Medicare patients are age 65+, there would be fewer prostatectomies because older patients with localized PCa are often not considered candidates for this surgery. Instead, they are sent for radiation. However, a German authority, Dr. Axel Heidenreich (director of the urology clinic, University Hospital, Aachen, Germany) points out, “The significant age difference…raises the question if (privately insured) patients have better access to the healthcare system in terms of early detection of prostate cancer as compared to the Medicare patients.”
Regionally, patient care in the northeast is influenced by patterns of physician density: areas with greater numbers of radiation oncologists had higher rates of radiation therapy, and those with more urologists per capita had higher rates of prostatectomy. However, physician distribution/density made no difference in western or southern regions of the U.S. One of the study authors, Dr. K. Clinton Cary (Urology Dept., Indiana University School of Medicine), theorized that reimbursement level for procedures might also affect treatment recommendations, with higher reimbursement levels driving one procedure over another; however, the study did not include data on reimbursements.
“Patients should largely rely on their treating physicians for treatment advice,” Cary said. “Patients may consider seeking second opinions from high-volume centers which may include their local academic medical centers that have experience with all treatment options and can report their own tracked outcomes.” In other words, when it comes to treatment for prostate cancer, it is the responsibility of the patient to explore what influences, besides best clinical decisions, might be behind a treatment recommendation. Unequal access to prostate cancer treatment is a sobering thought, but with good questions, patients can level the playing field.
[i] Doyle, Kathryn. Treatment for prostate cancer varies by area of U.S. Reuters Health, Mar 4, 2015.