Geographic and Socioeconomic Variation in the Treatment of Prostate Cancer

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Abstract
Within a framework of quality assessment, primary treatment choice constitutes an indicator of quality of care. This study examines geographic and socioeconomic variation in the primary treatment of men with prostate cancer during the era of prostate-specific antigen testing. Using the National Cancer Institute's Surveillance, Epidemiology, and End Results public use data files, we identified men with localized/regional prostate cancer who underwent surgery, radiation therapy, or watchful waiting. We used the year 2000 US Census information to ascribe education and income levels to these men based on their county of residence and ethnicity. Among the 96,769 men with localized/regional prostate cancer (during 1995 to 1999) who had sufficient information for analysis, we observed significant geographic variation nationwide in surgical, radiation, and watchful waiting treatment rates (P <.0015). Patterns noted 10 years ago, such as higher surgical rates in western regions, persisted. Ethnicity, income, and grade were all independently associated with primary treatment, or lack thereof. Blacks and low-income patients had the lowest rates of surgery and radiation. Grade was the best predictor of aggressive treatment. Nonclinical factors, such as ethnicity and income, were associated with the use of watchful waiting rather than surgery or radiation in men with early-stage prostate cancer. These findings have implications for quality of care.