Prostate cancer: socio-economic, geographical and private-health insurance effects on care and survival

Abstract

Objective: To examine the effects of demographic, geographical and socio-economic factors, and the influence of private health insurance, on patterns of prostate cancer care and 3-year survival in Western Australia (WA).

Patients and methods: The WA Record Linkage Project was used to extract all hospital morbidity, cancer and death records of men diagnosed with prostate cancer between 1982 and 2001. The likelihood of having a radical prostatectomy (RP) was estimated using logistic regression, and the likelihood of death 3 years after diagnosis was estimated using Cox regression.

Results: The proportion of men undergoing RP increased six-fold, from 3.1% to 20.1%, over the 20 years, whilst non-radical surgery (transurethral, open or closed prostatectomy) simultaneously halved to 29%. Men who had RP were typically younger, married and with less comorbidity. Patients with a first admission to a rural hospital were much less likely to have RP (odds ratio 0.15; 95% confidence interval, CI, 0.11-0.21), whereas residence alone in a rural area had less effect (0.54, 0.29-1.03). A first admission to a private hospital increased the likelihood of having RP (2.40, 2.11-2.72), as did having private health insurance (1.77, 1.56-2.00); being more socio-economically disadvantaged reduced RP (0.63, 0.47-0.83). The 3-year mortality rate was greater with a first admission to a rural hospital (relative risk 1.22; 95% CI 1.09-1.36) and in more socio-economically disadvantaged groups (1.34, 1.10-1.64), whereas those admitted to a private hospital (0.77, 0.71-0.84) or with private health insurance (0.82, 0.76-0.89) fared better. Men who had RP had better survival than those who had non-radical surgery (4.85, 3.52-6.68) or no surgery (6.42, 4.65-8.84), although this may be an artefact of a screening effect.

Conclusion: The 3-year survival was poorer and the use of RP less frequent in men from socio-economically and geographically disadvantaged backgrounds, particularly those admitted to rural or public hospitals, and those with no private health insurance.