Clinical Practice Guidelines for the management of locally advanced ...

9 SOCIO-ECONOMIC ASPECTS OF ADVANCED
PROSTATE CANCER
9.1 Introduction
Adverse social and economic circumstances are well-recognised determinants of access to and use of
health care. Less affluent or socially disadvantaged people live shorter lives and suffer more illness
than those who are well off. 1 Guideline development needs to consider how issues such as income,
education, occupation or employment, ethnicity, indigenous status, literacy, and place of residence
affect risk factors, use of health care services and outcomes of care.
There is growing evidence that socio-economic status (SES) is associated with prostate cancer
outcomes, particularly participation in PSA testing, patterns of care for localised disease and with
survival and mortality outcomes. Most of this evidence is based on American or European studies.
Randomised controlled trials rarely report whether trial selection is associated with social class or
whether interventions for advanced prostate cancer are confounded by SES. The relationships
between SES and prostate cancer incidence, mortality and survival in Australia are poorly understood
and even less is known about the association between SES and advanced prostate cancer.
9.2 Socio-economic status
A number of studies have demonstrated a higher risk of diagnosis of prostate cancer in men from
higher SES groups. This is likely to be related to higher prevalence of prostate cancer testing in those
with higher education, income and health-seeking behaviours. In New South Wales between 2002 and
2006, the incidence of prostate cancer was 15% higher than average in men resident in the highest
socio-economic status areas, compared to an 8% lower risk in the lowest SES group. However there
was no significant difference in mortality rates by SES groups. 2 Hall, using linked administrative data
from Western Australia, found higher three-year mortality from prostate cancer in more socioeconomically
disadvantaged groups (relative risk=1.34, 95% CI=1.10 to 1.64), whereas those
admitted to a private hospital (relative risk=0.77, 95% CI=0.71 to 0.84) or with private health
insurance (relative risk=0.82, 95% CI=0.76 to 0.89) fared better. 3 International studies have shown
that men with localised disease with lower incomes are less likely to be treated at all, and if treated for
localised cancer they are less likely to have prostatectomy and more likely to have radiation therapy. 4,5
A number of studies have shown that men with higher incomes and private health insurance status are
more likely to have aggressive treatment, better quality of life and lower mortality from prostate
cancer. 6–9 The role of income, education and health insurance in the determination of advanced
prostate cancer outcomes in Australia has never been explored.
9.3 Accessibility
Coory and Baade 10 , using administrative data for the whole of Australia, found a statistically significant
and increasing excess risk for prostate cancer mortality in regional and rural areas. In 2000–2002, the
excess (compared with capital cities) was 21% (95% CI=14% to 29%). The authors suggested that
this was likely related to lower rates of screening with PSA tests and treatment with radical
prostatectomy in rural and regional Australia. 10 Western Australia data indicate that the three-year
mortality rate for prostate cancer was greater with a first admission to a rural hospital (relative
risk=1.22, 95% CI=1.09 to 1.36) compared to non-rural hospitals. 3 A survival analysis comparing
rural and remote residents of NSW found a more than three-fold relative excess risk of death by five
years in men from rural and remote NSW (relative risk=3.38, 95% CI=2.21 to 5.16). This was partly
driven by later stage of disease at diagnosis in men from rural and remote areas. 11 An analysis of
linked data for NSW for the period 1993–2002 also showed associations between SES and rural/urban
areas of residence and the type of treatment received. Prostate cancer patients from less accessible
Clinical practice guidelines for the management of locally advanced and metastatic prostate cancer
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