Abstract
Purpose:
Cardiovascular disease (CVD) is a common cause of mortality among men with prostate cancer. However, receipt of preventive care and management of pre-existent CVD has not been well studied in prostate cancer survivors.
Methods:
This study examined a prospective cohort of men newly diagnosed with localized prostate cancer between 2011–2013 throughout North Carolina linked to Medicare and private insurance claims and clinical data from the Veterans Affairs (VA). In patients without pre-existent CVD, the primary outcome was a composite measure of annual preventive care (blood glucose screening, cholesterol level testing, and ≥1 primary care provider visit). In patients with pre-existent CVD, the primary outcome was annual cardiologist visit; blood glucose, cholesterol level testing, and primary care visits were also assessed.
Results:
Our sample comprised 492 patients successfully linked to insurance claims and/or VA data, among whom 103 (20.9%) had pre-existent CVD. Receipt of preventive care declined from 52.7% (95% confidence interval [CI], 47.7% to 57.6%) during the first year after prostate cancer diagnosis to 40.8% (95% CI: 33.7% to 48.4%) during the third year. Among patients with pre-existent CVD, only 23.4% (95% CI: 13.6% to 37.2%) visited a cardiologist in all three years. Black men were more likely than White men to visit a cardiologist the first year (risk ratio [RR] = 1.72, 95% CI: 1.10 to 2.71).
Conclusion:
In a population-based cohort of prostate cancer survivors, receipt of CVD preventive care declined over time and frequency of cardiologist-led management of pre-existent CVD was low.
Implications for cancer survivors:
There is a need to improve clinical strategies for reducing cardiovascular risk and managing pre-existent CVD in prostate cancer survivors.
Keywords: Prostatic neoplasms, cardiovascular diseases, survivorship, race, health services
Introduction
The burden of prostate cancer in the United States is substantial. Prostate cancer survivors exceed 3.6 million and represent over 40% of American male cancer survivors [1]. At the time of their prostate cancer diagnosis, most men have other health risks, including cardiovascular disease (CVD) and clinical conditions that increase their underlying risk of developing CVD (e.g., diabetes and hypercholesterolemia). Furthermore, because prostate cancer is often slow-growing, most men with prostate cancer are more likely to die from CVD than their prostate cancer [2]. The prevalence of and mortality from CVD [2–4] in men with prostate cancer signifies the importance of CVD prevention and management as components of high-quality survivorship care [5].
Receipt of CVD preventive care and management of CVD existent prior to prostate cancer diagnosis (i.e., pre-existent CVD) has not been well studied among prostate cancer survivors. In addition, prior research has not assessed whether receipt of CVD preventive care and management of pre-existent CVD differs among certain patient groups that are historically known to encounter care disparities related to prostate cancer, specifically Black men and men who live in rural areas. To address this knowledge gap, we evaluated receipt of CVD preventive care and management of pre-existent CVD using a unique dataset that includes contemporary men with localized prostate cancer enrolled in a prospective population-based cohort, with data collected from each individual and linked claims data.
Methods
Data Sources and Study Population
The North Carolina Prostate Cancer Comparative Effectiveness and Survivorship Study (NC ProCESS) is a population-based, prospective cohort study of men with localized prostate cancer. From 2011–2013, newly diagnosed prostate cancer participants were identified through the Rapid Case Ascertainment program of the North Carolina Central Cancer Registry (NCCCR) and contacted for enrollment from across all 100 counties in North Carolina. All study participants were enrolled prior to treatment and followed prospectively. Additional details about NC ProCESS are available in prior publications [6,7].
Participants in NC ProCESS self-reported sociodemographic characteristics, including race, ethnicity, education, insurance coverage, and marital status. Rurality was classified using participants’ county of residence at prostate cancer diagnosis and 2013 Rural-Urban Continuum Codes (RUCCs) [8]. We considered urban participants to be those living in metropolitan counties (RUCC designation 1–3) and rural participants to be those living in non-metropolitan counties (RUCC designation 4–9). Details about each participant’s prostate cancer diagnosis, including age at diagnosis, PSA level, Gleason score and clinical stage, were provided by the NCCCR.
Individual-level data were linked to Medicare and private health insurance claims data through deterministic and probabilistic linkage methods [9,10]. In addition, for NC ProCESS participants who accessed care in the Veterans Affairs (VA) Health System, linkage with clinical data from the nationwide VA Corporate Data Warehouse was performed using patient identifiers. Medicare and private health insurance claims data and VA data were used to identify patients with CVD, relevant cardiovascular risk factors (i.e., diabetes, hyperlipidemia, and hypertension), receipt of CVD preventive care and management of pre-existent CVD. This study was approved by the institutional review boards of the University of North Carolina at Chapel Hill and the Durham VA Health Care System.
Patients were categorized according to whether they had a baseline history of CVD (i.e., pre-existent CVD), defined as at least one claim or visit to a VA facility with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), Current Procedural Terminology, or Healthcare Common Procedure Coding System codes in the 12 months preceding their prostate cancer diagnosis for acute coronary syndrome, angina, history of myocardial infarction, history of coronary revascularization, ischemic stroke, peripheral arterial disease, or transient ischemic attack (eTable 1 in the Supplement). Patients with a history of CVD prior to their prostate cancer diagnosis were eligible for inclusion in analyses of pre-existent CVD management. On the other hand, individuals with no baseline history of CVD were eligible for inclusion in analyses of preventive care. Those who developed CVD following prostate cancer were excluded from subsequent analyses of preventive care and were not included in the analysis of CVD management. In addition, individuals with a baseline history of diabetes prior to their prostate cancer diagnosis were eligible for inclusion in analyses of diabetes-related care, irrespective of CVD history. For each evaluation, patients were included if they had continuous enrollment in fee-for-service Medicare and/or private health insurance or VA data 12 months prior to their prostate cancer diagnosis through the period of analysis.
Outcomes
Among patients without pre-existent CVD, the primary outcome of interest was a composite measure of annual preventive care, which included claims or visit to a VA facility for blood glucose screening, cholesterol level testing, and at least one visit to a primary care provider during the year of analysis; this was assessed using claims data (eTable 1 in the Supplement) [11,12]. Primary care visits included visits with a general practitioner, family practice, internal medicine, or geriatric medicine provider.
Among patients with pre-existent CVD, the primary outcome of interest was an annual office visit with a cardiologist [13]. Annual blood glucose screening, cholesterol level testing, and visits to a primary care provider were also assessed.
As a secondary outcome, we evaluated whether patients with baseline diabetes received routine monitoring of hemoglobin A1c (A1c) or fructosamine levels and had routine primary care provider visits. These outcomes were assessed every 6 months after prostate cancer diagnosis (i.e., 0 to 6 months; 6 to 12 months; 12 to 18 months; 18 to 24 months; 24 to 30 months; and 30 to 36 months) based on guideline recommendations for monitoring (at least two times a year) of A1c in individuals with diabetes [14].
Statistical Analysis
For each outcome described above, we calculated the proportion of participants who received care within each period (annual for the primary outcomes, and every 6 months for the secondary outcomes). The 95% CIs for proportions were calculated using the Wilson Score method [15]. We used Poisson regression analyses with robust standard errors to identify patient characteristics associated with the probability of receiving the composite measure of preventive care. In multivariable analyses of the composite measure of preventive care, covariates included the main predictors of interest (patient race and rurality), age, prostate cancer risk group, history of hypertension, history of hyperlipidemia, and history of diabetes.
Since routine monitoring of blood glucose and cholesterol may not be warranted in men under 65 who do not have additional risk factors (e.g., diabetes, obesity, current smoker) for cardiovascular disease, a sensitivity analysis was conducted to examine the robustness of results for the primary outcome (i.e., annual preventive care). In this approach, analysis of annual preventive care was limited to the subset of men who were age ≥65 years at the time of prostate cancer diagnosis or had a 10-year risk of CVD ≥7.5% (i.e., intermediate or greater risk). The 10-year risk was estimated using the American College of Cardiology ASCVD Risk Estimator Plus [16] and baseline patient history of diabetes, hyperlipidemia, hypertension, and smoking (current or former).
Statistical significance was defined using a 2-sided alpha level of 0.05 for all analyses. All analyses were conducted using SAS 9.4 and Excel 16.0.
Results
Patient Demographics
Of 1387 NC ProCESS study participants, 1117 (81%) were successfully linked to Medicare and/or private health insurance enrollment data and 108 (8%) were linked to VA data, including 25 participants who were not otherwise linked to other insurance enrollment information. Among the 1142 participants linked to insurance claims or VA data, 492 (43%) had continuous data 12 months prior to through at least 12 months following prostate cancer diagnosis and were included in further analyses. Of the 492 men included in this study, 30% were aged less than 65 years at the time of their prostate cancer diagnosis, 21% were Black, 65% resided in an urban area, 34% had a history of diabetes, over 80% had a history of hypertension and/or hyperlipidemia, and approximately 21% had pre-existent CVD (Table 1).
Table 1.
Baseline characteristics of study cohort
| Characteristic | N = 492 |
|---|---|
| Age, mean (SD), y | 66.4 (7.3) |
| Age group, n (%), y | |
| <65 | 147 (29.9) |
| 65–69 | 182 (37.0) |
| 70+ | 163 (33.1) |
| Race, n (%) | |
| Black | 103 (20.9) |
| White | 389 (79.1) |
| Married, n (%) | 324 (65.8) |
| Urban residence, n (%)* | 320 (65.0) |
| Comorbidities at baseline, n (%) | |
| Pre-existent cardiovascular disease | 103 (20.9) |
| Angina | 14 (2.8) |
| Coronary artery disease | 11 (2.2) |
| History of myocardial infarction | 53 (10.8) |
| History of stroke or TIA | 20 (4.1) |
| Diabetes | 169 (34.4) |
| Hyperlipidemia | 327 (80.1) |
| Hypertension | 322 (81.1) |
| Obesity | 94 (19.1) |
| History of tobacco use at baseline, n (%) | |
| Current smoker | 50 (10.2) |
| Former smoker | 239 (48.6) |
| NCCN prostate cancer risk group, n (%) | |
| Low risk | 258 (52.4) |
| Intermediate risk | 175 (35.6) |
| High risk | 59 (12.0) |
| Initial prostate cancer treatment, n (%) | |
| Active surveillance | 129 (26.2) |
| Radiation therapy | 131 (26.6) |
| Radical prostatectomy | 154 (31.3) |
| Other | 78 (15.9) |
| Received ADT during initial treatment, n (%) | 57 (11.6) |
Abbreviations: ADT = androgen deprivation therapy; NCCN = National Comprehensive Cancer Network; SD = standard deviation; TIA = transient ischemic attack.
Urban residence is defined as living in a county assigned 2013 US Department of Agriculture Rural-Urban Continuum Codes 1–3.
Preventive Care among Participants without Pre-existent CVD
Receipt of the composite measure for preventive care declined over time, from 52.7% (95% confidence interval [CI], 47.7% to 57.6%) during the first year after prostate cancer diagnosis to 40.8% (95% CI: 33.7% to 48.4%) during the third year (Figure 1). This composite measure indicates the participants who received all 3 recommended services: primary care provider visit, blood glucose and cholesterol testing during a single year. Only 24.3% (95% CI: 18.4% to 31.2%) of participants received the composite measure of preventive care in all three years. Approximately 59 of 389 (15%), 14 of 298 (5%), and 11 of 169 (7%) of participants were newly diagnosed with CVD in the first, second, and third years after prostate cancer diagnosis, respectively. No significant differences in the composite measure for preventive care were observed by race or patient rurality in unadjusted (Table 2) or multivariable adjusted analyses (eTable 2 in the Supplement).
Figure 1.
Percentage of men without pre-existent cardiovascular disease who received annual blood glucose monitoring, cholesterol screening, and a primary care provider visit during the first 3 years following their prostate cancer diagnosis. Blue = year 1; orange = year 2; gray = year 3; yellow = years 1–3. Error bars represent the 95% confidence intervals for the proportions.
Table 2.
Percentage (95% confidence interval) of men without pre-existent cardiovascular disease who received annual blood glucose screening, cholesterol screening, and a primary care provider visit during the first 3 years following their prostate cancer diagnosis, by patient race and rurality.
| Time from diagnosis | No. participants | All 3 items | Blood glucose screen | Cholesterol screen | Primary care visit | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| White | Black | White | Black | White | Black | White | Black | White | Black | |
| Year 1 | 316 | 73 | 53.5 (48.0 to 58.9) | 49.3 (38.2 to 60.5) | 75.6 (70.6 to 80.0) | 80.8 (70.3 to 88.2) | 68.7 (63.4 to 73.5) | 67.1 (55.7 to 76.8) | 77.8 (73.0 to 82.1) | 74.0 (62.9 to 82.7) |
| Year 2 | 234 | 64 | 51.3 (44.9 to 57.6) | 45.3 (33.7 to 57.4) | 65.4 (59.1 to 71.2) | 54.7 (42.6 to 66.3) | 77.8 (72.0 to 82.6) | 71.9 (59.9 to 81.4) | 79.1 (73.4 to 83.8) | 75.0 (63.2 to 84.0) |
| Year 3 | 134 | 35 | 41.0 (33.1 to 49.5) | 40.0 (25.6 to 56.4) | 57.5 (49.0 to 65.5) | 48.6 (33.0 to 64.4) | 73.1 (65.1 to 79.9) | 77.1 (61.0 to 87.9) | 76.1 (68.2 to 82.5) | 82.9 (67.3 to 91.9) |
| Across Years 1–3 | 134 | 35 | 24.6 (18.1 to 32.6) | <31.4 (<18.6 to <48.0)* | 41.0 (33.1 to 49.5) | 42.9 (28.0 to 59.1) | 52.2 (43.8 to 60.5) | 51.4 (35.6 to 67.0) | 64.9 (56.5 to 72.5) | 71.4 (54.9 to 83.7) |
| Rural | Urban | Rural | Urban | Rural | Urban | Rural | Urban | Rural | Urban | |
| Year 1 | 132 | 257 | 51.5 (43.1 to 59.9) | 53.3 (47.2 to 59.3) | 79.5 (71.9 to 85.5) | 75.1 (69.5 to 80.0) | 69.7 (61.4 to 76.9) | 67.7 (61.8 to 73.1) | 75.8 (67.8 to 82.3) | 77.8 (72.4 to 82.5) |
| Year 2 | 106 | 192 | 46.2 (37.0 to 55.7) | 52.1 (45.0 to 59.0) | 58.5 (49.0 to 67.4) | 65.6 (58.7 to 72.0) | 74.5 (65.5 to 81.9) | 77.6 (71.2 to 82.9) | 77.4 (68.5 to 84.3) | 78.6 (72.3 to 83.9) |
| Year 3 | 55 | 114 | 45.5 (33.0 to 58.5) | 38.6 (30.2 to 47.8) | 56.4 (43.3 to 68.6) | 55.3 (46.1 to 64.1) | 80.0 (67.6 to 88.4) | 71.1 (62.1 to 78.6) | 80.0 (67.6 to 88.4) | 76.3 (67.7 to 83.2) |
| Across Years 1–3 | 55 | 114 | 30.9 (20.3 to 44.0) | 21.1 (14.6 to 29.4) | 45.5 (33.0 to 58.5) | 39.5 (31.0 to 48.6) | 58.2 (45.0 to 70.3) | 49.1 (40.1 to 58.2) | 67.3 (54.1 to 78.2) | 65.8 (56.7 to 73.9) |
Data coarsened to comply with CMS cell size suppression policy.
CVD Management among Participants with Pre-existent CVD
Approximately 40% of participants with pre-existent CVD visited with a cardiologist in the first year after prostate cancer diagnosis with similar proportions observed in the second and third years (Table 3); only 23.4% (95% CI: 13.6% to 37.2%) of participants visited with a cardiologist in all three years. Black men were more likely than White men to visit with a cardiologist in the first year after prostate cancer diagnosis (risk ratio [RR] = 1.72, 95% CI: 1.10 to 2.71). Approximately half of men residing in a rural area and 33%–38% of men residing in an urban area had a visit with a cardiologist in the first, second, or third year after prostate cancer diagnosis; these proportions were not statistically significantly different between rural vs urban participants.
Table 3.
Percentage (95% confidence interval) of men with pre-existent cardiovascular disease who had an annual visit with a cardiologist during the first 3 years after their prostate cancer diagnosis, overall and by patient race and rurality.
| Time from diagnosis | Race | Rurality | ||||
|---|---|---|---|---|---|---|
| N | All | White | Black | Urban | Rural | |
| Year 1 | 103 | 39.8 (30.9 to 49.5) | 32.9 (23.2 to 44.3) | 56.7 (39.2 to 72.6) | 33.3 (22.9 to 45.6) | 50.0 (35.2 to 64.8) |
| Year 2 | 92 | 43.5 (33.8 to 53.7) | 43.9 (32.6 to 55.9) | 42.3 (25.5 to 61.1) | 37.5 (26.0 to 50.6) | 52.8 (37.0 to 68.0) |
| Year 3 | 47 | 40.4 (27.6 to 54.7) | --* | --* | --* | --* |
| Across Years 1–3 | 47 | 23.4 (13.6 to 37.2) | --* | --* | --* | --* |
Data suppressed to comply with CMS cell size suppression policy.
Among men with pre-existent CVD, the percentage who received the composite measure of blood glucose testing, cholesterol testing, and primary care provider visit was similar to that observed in men without pre-existent CVD (eTable3 in the Supplement). Approximately 57% received all 3 services during the first year after prostate cancer diagnosis, with roughly 30% receiving them in all 3 years. Frequency of primary care visits was relatively high as 80% of men with pre-existent CVD visited a primary care provider during the first, second, and third years.
Diabetes Care
In participants with baseline diabetes, the proportion who received A1c or fructosamine testing and the proportion with a visit to a primary care provider were relatively consistent across each 6-month interval after prostate cancer diagnosis (eTable 4 in the Supplement). Receipt of A1c or fructosamine testing ranged from 64.7% (95% CI: 55.8% to 72.7%) to 70.4% (95% CI: 62.9% to 77.0%) and the proportion with a visit with a primary care provider ranged from 77.5% (95% CI: 70.6% to 83.2%) to 83.5% (95% CI: 74.2% to 89.9%). Approximately 31.8% (95% CI: 22.8% to 42.3%) of participants received A1c or fructosamine testing and 67.1% (95% CI: 56.5% to 76.1%) had a visit with a primary care provider in every 6-month interval during the three years of follow-up.
There were no statistically significant differences in receipt of A1c or fructosamine testing or primary care provider visit by race or urban/rural residence.
Sensitivity Analysis
Limiting the analysis of annual preventive care to men who were age ≥65 years at the time of prostate cancer diagnosis or had a 10-year risk of CVD ≥7.5% yielded a slightly smaller initial sample (n=349 vs. n=389), but generally similar results to the primary approach. For example, receipt of the composite measure for preventive care (i.e., primary care provider visit, blood glucose and cholesterol testing) was 55.9% (95% CI, 50.6% to 61.0%) during the first year and declined to 41.7% (95% CI: 34.4% to 49.4%) during the third year (eTable 5 in the Supplement). Likewise, no significant differences in the composite measure for preventive care were observed by race or patient rurality in multivariable adjusted analyses (eTable 6 in the Supplement).
Discussion
In a population-based cohort of men with newly diagnosed prostate cancer who were followed prospectively, we evaluated the receipt of CVD preventive care and management of pre-existent CVD. Our results showed that receipt of preventive care, using a composite measure comprised of blood glucose screening, cholesterol screening, and primary care visit, is generally poor. Only 24.3% of prostate cancer survivors without pre-existent CVD received guideline-recommended CVD preventive care in each of the first 3 years after prostate cancer diagnosis. Similarly, among men with pre-existent CVD, only 23.4% had an annual visit with a cardiologist during the first 3 years and, despite a high rate of primary care visits, less than half received annual blood glucose and cholesterol testing during this period.
Although cardiovascular disease is a leading cause of mortality among prostate cancer survivors [2], few studies have examined receipt of CVD care in this patient population. We found two published studies which examined short-term CVD care among subgroups of prostate cancer survivors. In a small multi-institutional study, 63% of 103 analyzed patients treated with radiotherapy and androgen deprivation therapy (ADT) received monitoring for cardiovascular risk factors concordant with American Heart Association guidelines during the first year after completion of radiation therapy [4]. In a cross-sectional study of over 90,000 Veterans with prostate cancer diagnosed between 2010 and 2017, approximately two-thirds without a history of CVD received a comprehensive assessment of cardiovascular risk factors (including systolic and diastolic blood pressure, cholesterol level, and blood glucose level) in the first 6 months after prostate cancer diagnosis or the start of ADT [17]. The current study is consistent with and extends findings from these two prior studies. Importantly, we found that rates of CVD preventive care and management of pre-existent CVD decreased over time for prostate cancer survivors. The low proportion of prostate cancer survivors receiving the composite measure of preventive care can be explained in part by the low rates of blood glucose screening, particularly in the second and third years after prostate cancer diagnosis. Among participants without pre-existent CVD, blood glucose screening decreased from 77% in the first year after diagnosis to 56% in the third year, with only 41% of participants receiving a blood glucose screening in all three years. When examining care for the first 3 years after prostate cancer diagnosis, fewer than 25% of prostate cancer survivors received guideline-recommended CVD care. This demonstrates the importance of longer-term follow-up when examining the quality of survivorship care.
Racial disparities in prostate cancer have been well documented. Black men are more likely than White men to have socioeconomic barriers to timely, high-quality care, which contributes to lower rates of definitive treatment and higher rates of mortality [18–20]. Interestingly however, we found that receipt of CVD preventive care and management of pre-existent CVD were generally similar between Black and White men. In fact, among participants with pre-existent CVD, Black men were nearly twice as likely as White men to visit a cardiologist within the first year after prostate cancer diagnosis. The proportion of participants with an annual cardiologist visit during years 1 to 3 after their prostate cancer diagnosis ranged from 42% to 57% among Black men and from 33% to 44% among White men. Comparable health insurance coverage among Black and White men in this study may have allowed equitable access to care, which could help explain some of these findings. Rural-urban disparities in prostate cancer have also been previously described. Geographical differences can affect distances needed to travel for care and thus, access to and types of health care services received. Men from rural areas are less likely to receive definitive treatment and patient rurality affects the type of treatment received [21–23]. Still, in our study, we found no significant differences in receipt of CVD preventive care or management of pre-existent CVD by rural-urban residence.
Estimated rates of CVD preventive care in the general population vary depending on the age range, sex, period and setting of the study population [24–28]. In a recent study of the National Health and Nutrition Examination Survey (NHANES), only 46% of the study population meeting recommended screening criteria for diabetes reported receipt of blood glucose screening within the past 3 years, including only 50% of those 45 years and older [25]. In a separate study of NHANES data, approximately 70% of adult respondents reported receipt of lipid testing within the past 5 years, including 66% of men [28]. In the current study, we found that over 75% of men without pre-existent CVD received a blood glucose screening and more than 75% had a lipid test within the first 3 years of their prostate cancer diagnosis; however, only 40%–50% of men received these tests annually in all 3 years. Receipt of a blood glucose screen was notably higher in the first year after prostate cancer diagnosis than in the subsequent years. Prostate cancer patients typically have broad engagement with the healthcare system around the time of their cancer diagnosis, which may increase the likelihood of receiving other health services during that period, including CVD preventive care.
This study has several limitations. Although we successfully linked over 80% of the cohort participants to claims and/or VA data, it is possible that the other 20% (mainly uninsured patients) may have different results. However, our overall finding that CVD care among prostate cancer survivors is an area that needs improvement likely remains true, and perhaps even more so for uninsured individuals. Furthermore, claims data are limited in their ability to identify blood pressure assessment; still, this limitation is reduced by our evaluation of primary care visits, which we used as a surrogate because these visits likely included a blood pressure assessment. Our analysis of CVD management was limited to survivors with pre-existent CVD and, therefore, it is important to note that rates of CVD management may have been different among survivors who developed CVD after their prostate cancer diagnosis. Lastly, use of annual cardiologist visit to assess CVD management may underestimate the true receipt of cardiovascular care as some survivors with pre-existent CVD may be adequately managed by their primary care provider or other specialists (e.g., neurologists among survivors with a history of stroke). Indeed, we observed a relatively high rate of annual primary care provider visits among survivors with pre-existent CVD. Nevertheless, annual receipt of the composite of blood glucose screening, cholesterol level testing, and provider visit in survivors with pre-existent CVD was low.
This study also has notable strengths. First, to the best of our knowledge, this is the first study to evaluate differences in CVD preventive care and management of pre-existent CVD among prostate cancer survivors by patient race and rurality. We evaluated outcomes in a population-based cohort of prostate cancer patients, and we were able to assemble a diverse cohort that included 21% Black prostate cancer survivors and 35% who lived in rural areas. Though we did not observe differences in the receipt of preventive care by either patient race or rurality, this suggests that use of preventive care following prostate cancer diagnosis in men without pre-existent CVD was relatively poor in all patient groups. Finally, the linkage and use of multiple data sources, including cancer registry data, administrative claims data from Medicare and private insurance, and data from the VA Corporate Data Warehouse was unique and allowed for a more comprehensive view of participants. Incorporation of data from the VA was particularly innovative and allowed capture of care services that were not identifiable through claims data. The ability of our cohort and data linkage to examine care in patients older and younger than 65 (not limited to a Medicare population) was another unique strength.
This analysis of a population-based cohort of men with localized prostate cancer linked to administrative claims data from Medicare, private insurance, and clinical data from the VA highlights an existing need to improve the administration of preventive care for and management of CVD, a leading cause of morbidity and mortality in prostate cancer survivors. Decline in the receipt of preventive care over time and the low frequency of cardiologist-led management of pre-existent CVD extends the need for greater attention to and improvement upon clinical strategies for lessening cardiovascular risks in prostate cancer survivors. Given the large number of prostate cancer survivors in the US, strategies to improve survivorship care specifically related to CVD preventive care and management of pre-existent CVD will lead to a sizable impact on reducing the morbidity and mortality burden in prostate cancer survivors.
Supplementary Material
Acknowledgements
Work on this study was supported by the Cancer Information and Population Health Resource, UNC Lineberger Comprehensive Cancer Center, with funding provided by the University Cancer Research Fund via the state of North Carolina. We thank the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) at the Durham Veterans Affairs Health Care System for their support.
Funding
This work was supported by the National Institute On Minority Health And Health Disparities of the National Institutes of Health (R21MD012465); and the Agency for Healthcare Research and Quality, US Department of Health and Human Services as part of the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) program (contract HHSA29020050040I). The funders had no role in the design of the study; the collection, analysis, and interpretation of the data; the writing of the manuscript; and the decision to submit the manuscript for publication.
Footnotes
Disclosures
AJK reported receiving personal fees from Kite Pharma and Atara Biotherapeutics outside the submitted work. RCC reported receiving personal fees from AbbVie, Accuray, Bayer, Blue Earth Diagnostics, and Myovant outside the submitted work. The remaining authors have no potential conflicts of interest to disclose.
Disclaimer: The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the Agency for Healthcare Research and Quality, Duke University, the U.S. Department of Veterans Affairs, or the U.S. government.
Ethics approval
The is an observational study of existing data. The study received expedited review and approval by the Institutional Review Board of the University of North Carolina at Chapel Hill and the Institutional Review Board of the Durham Veterans Affairs Medical Center.
Data availability
Data underlying this study are not available to other researchers due to policies of the data providers regarding data access and sharing.
References
- 1.Miller KD, Nogueira L, Mariotto AB, et al. Cancer treatment and survivorship statistics, 2019. CA Cancer J Clin. 2019;69(5):363–385. doi: 10.3322/caac.21565 [DOI] [PubMed] [Google Scholar]
- 2.Shikanov S, Kocherginsky M, Shalhav AL, Eggener SE. Cause-specific mortality following radical prostatectomy. Prostate Cancer Prostatic Dis. 2012;15(1):106–110. doi: 10.1038/pcan.2011.55 [DOI] [PubMed] [Google Scholar]
- 3.Pinthus JH, Shayegan B, Klotz L, et al. The prevalence of cardiovascular disease and its risk factors among prostate cancer patients treated with and without androgen deprivation. J Clin Oncol. 2020;38(6_suppl):364. doi: 10.1200/JCO.2020.38.6_suppl.364 [DOI] [Google Scholar]
- 4.Holmes JA, Anderson RF, Hoffman LG, et al. Cardiovascular Preventive Care and Coordination of Care in Prostate Cancer Survivors: A Multi-Institutional Prospective Study. Int J Radiat Oncol Biol Phys. 2019;103(1):112–115. doi: 10.1016/j.ijrobp.2018.07.2018 [DOI] [PubMed] [Google Scholar]
- 5.Hewitt M, Greenfield S, Stovall E. From Cancer Patient to Cancer Survival: Lost in Transition. Washington, DC: National Academy Press; 2005. [Google Scholar]
- 6.Chen RC, Carpenter WR, Kim M, et al. Design of the North Carolina Prostate Cancer Comparative Effectiveness and Survivorship Study (NC ProCESS). J Comp Eff Res. 2015;4(1):3–9. doi: 10.2217/cer.14.67 [DOI] [PubMed] [Google Scholar]
- 7.Chen RC, Basak R, Meyer AM, et al. Association between choice of radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance and patient-reported quality of life among men with localized prostate cancer. JAMA. 2017;317(11):1141–1150. doi: 10.1001/jama.2017.1652 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.US Department of Agriculture, Economic Research Service, Rural Urban Continuum Codes. https://www.ers.usda.gov/data-products/rural-urban-continuum-codes.
- 9.Meyer A-M, Olshan AF, Green L, et al. Big data for population-based cancer research: the integrated cancer information and surveillance system. N C Med J. 2014;75(4):265–269. doi: 10.18043/ncm.75.4.265 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Dusetzina SB, Tyree S, Meyer A-M, Meyer A, Green L, Carpenter WR. An Overview of Record Linkage Methods. Rockville (MD); 2014. doi:AHRQ No.14-EHC033 [Google Scholar]
- 11.Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;316(19):1997–2007. doi: 10.1001/jama.2016.15450 [DOI] [PubMed] [Google Scholar]
- 12.Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11):e596–e646. doi: 10.1161/CIR.0000000000000678 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Armenian SH, Lacchetti C, Barac A, et al. Prevention and Monitoring of Cardiac Dysfunction in Survivors of Adult Cancers: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2017;35(8):893–911. doi: 10.1200/JCO.2016.70.5400 [DOI] [PubMed] [Google Scholar]
- 14.American Diabetes Association. 6. Glycemic Targets: Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021;44(Suppl 1):S73–S84. doi: 10.2337/dc21-S006 [DOI] [PubMed] [Google Scholar]
- 15.Wilson EB. Probable Inference, the Law of Succession, and Statistical Inference. J Am Stat Assoc. 1927;22(158):209–212. doi: 10.1080/01621459.1927.10502953 [DOI] [Google Scholar]
- 16.American College of Cardiology. ASCVD Risk Estimator Plus. October 2021. Accessed April 12, 2022. https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate [Google Scholar]
- 17.Sun L, Parikh RB, Hubbard RA, et al. Assessment and Management of Cardiovascular Risk Factors Among US Veterans With Prostate Cancer. JAMA Netw Open. 2021;4(2):e210070. doi: 10.1001/jamanetworkopen.2021.0070 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Moses KA, Orom H, Brasel A, Gaddy J, Underwood W 3rd. Racial/Ethnic Disparity in Treatment for Prostate Cancer: Does Cancer Severity Matter? Urology. 2017;99:76–83. doi: 10.1016/j.urology.2016.07.045 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Dess RT, Hartman HE, Mahal BA, et al. Association of Black Race With Prostate Cancer-Specific and Other-Cause Mortality. JAMA Oncol. 2019;5(7):975–983. doi: 10.1001/jamaoncol.2019.0826 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Underwood W 3rd, Jackson J, Wei JT, et al. Racial treatment trends in localized/regional prostate carcinoma: 1992–1999. Cancer. 2005;103(3):538–545. doi: 10.1002/cncr.20796 [DOI] [PubMed] [Google Scholar]
- 21.Maganty A, Sabik LM, Sun Z, et al. Under Treatment of Prostate Cancer in Rural Locations. J Urol. 2020;203(1):108–114. doi: 10.1097/JU.0000000000000500 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Baldwin L-M, Andrilla CHA, Porter MP, Rosenblatt RA, Patel S, Doescher MP. Treatment of early-stage prostate cancer among rural and urban patients. Cancer. 2013;119(16):3067–3075. doi: 10.1002/cncr.28037 [DOI] [PubMed] [Google Scholar]
- 23.Tang C, Lei X, Smith GL, et al. Influence of Geography on Prostate Cancer Treatment. Int J Radiat Oncol Biol Phys. 2021;109(5):1286–1295. doi: 10.1016/j.ijrobp.2020.11.055 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Rifas-Shiman SL, Forman JP, Lane K, Caspard H, Gillman MW. Diabetes and lipid screening among patients in primary care: a cohort study. BMC Health Serv Res. 2008;8:25. doi: 10.1186/1472-6963-8-25 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Kiefer MM, Silverman JB, Young BA, Nelson KM. National patterns in diabetes screening: data from the National Health and Nutrition Examination Survey (NHANES) 2005–2012. J Gen Intern Med. 2015;30(5):612–618. doi: 10.1007/s11606-014-3147-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Banerjee ES, Shaak K, Burgess N, Johnson M, Careyva B. Factors Associated with Clinician Adherence to USPSTF Diabetes Screening Recommendations. J Prim Care Community Health. 2021;12:21501327211016580. doi: 10.1177/21501327211016579 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Grant DSL, Scott RD, Harrison TN, et al. Trends in Lipid Screening Among Adults in an Integrated Health Care Delivery System, 2009–2015. J Manag Care Spec Pharm. 2018;24(11):1090–1101. doi: 10.18553/jmcp.2018.18100 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Gillespie CD, Keenan NL, Miner JB, Hong Y. Screening for lipid disorders among adults--National Health and Nutrition Examination Survey, United States, 2005–2008. MMWR Suppl. 2012;61(2):26–31. [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data underlying this study are not available to other researchers due to policies of the data providers regarding data access and sharing.