EARLY DIAGNOSIS OF PROSTATE CANCER

Report
Disparities in
Prostate Cancer Care:
The Alabama Experience
Thomas E. Moody, M.D.
(205) 930-0920

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


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.
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 has the third highest death rate due to prostate cancer in the
nation.
40
PROSTATE CANCER MORTALITY RATES: U.S./STATE, 2007-2009
35
30
25
ALABAMA
U.S.
20
15
10
5
D.C.
Mississippi
Alabama
Idaho
Maryland
Montana
Georgia
South Carolina
Louisiana
Wisconsin
North Carolina
Oregon
Ohio
Illinois
Minnesota
Virginia
Delaware
Nebraska
Arkansas
Washington
Tennessee
North Dakota
Connecticut
Maine
Indiana
Utah
Oklahoma
Colorado
Pennsylvania
Iowa
Kentucky
Massachusetts
U.S.
New Mexico
Nevada
California
New Hampshire
Michigan
Missouri
New Jersey
New York
Vermont
Alaska
West Virginia
South Dakota
Kansas
Rhode Island
Texas
Wyoming
Arizona
Florida
Hawaii
0
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.
70
ALABAMA
PROSTATE CANCER MORTALITY RATES: U.S./STATE, 2007-2009
60
U.S.
50
40
30
20
10
0
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.
Prostate Cancer Incidence and Mortality Rates for Alabama, 2000-2009
Alabama Statewide Cancer Registry. Rates are per 100,000 and age-adjusted to the 2000 U.S.
(19 age groups) standard.

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


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 AfricanAmerican males, compared to white males aged 50
and older (38.6% vs. 46.6%, respectively).
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).
 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).
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.
 Legislation
 Screenings
of AtRisk Populations
 Public
and Provider
Education
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.

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 physicianordered prostate cancer tests.

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.

Advance trips


Trips made to
screening locations to
meet with ADPH
officials, community
leaders, PCP’s, and
media
Publicity


Advance trip made on 10-19-10 before UHF's
free prostate cancer screening in Conecuh
County
Notices sent to churches, media, County Extension
Offices, Chambers of Commerce, PCP’s, businesses,
and prior participants
Website and social media postings

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

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.

“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

Primary care physicians are often the first point
of healthcare access and play a key role in
educating and screening their patients.

Continuing Medical
Education is an
important means of
filling in PCP
“knowledge gaps.”
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.

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.
Breast 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.
Breast 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.
American Cancer Society
Current Grants by Cancer Type as of 3/1/12
American Cancer Society. http://bit.ly/vTPjE4. Accessed May 25, 2012.

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.

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 countylevel urologic cancer mortality. J Clin Oncol. 2010 May 20;28(15): 2499-504.

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.

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
treatable with the right policies.

The status and impact of this legislation are
uncertain at this time.
Dr. Scott Tully of Urology Centers of Alabama waves as he rides in the Tour de Blue:
Cycling for Prostate Cancer Awareness event.
Disparities in
Prostate Cancer Care:
The Alabama Experience
Thomas E. Moody, M.D.
(205) 930-0920

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