title: Prostate cancer severity among low income, uninsured men.
abstract: OBJECTIVE
  The proportion of American men with organ confined, low risk prostate cancer has increased significantly during the last 2 decades. Whether this trend also applies to men at the extremes of socioeconomic disadvantage remains unknown. Therefore, we evaluated trends in prostate cancer severity in an ethnically diverse cohort of low income, uninsured men served by a state funded public health program in California.
  
  
  METHODS
  We performed a retrospective cohort study of 570 disadvantaged men enrolled in the California program from 2001 through 2006. Using routinely collected clinical variables we defined 2 measures of cancer severity as 1) the proportion of enrollees with metastases at diagnosis and 2) the proportions of men with nonmetastatic tumors whose cancers had low, intermediate or high risk features at diagnosis. We performed bivariate analyses to assess time trends in cancer severity.
  
  
  RESULTS
  Prostate specific antigen levels at diagnosis exceeded 10 ng/ml for 51% of enrollees, 50% had a Gleason score 7 or greater and 43% had clinical T stage T2 or greater. Of disadvantaged men 19% had metastatic cancer at diagnosis and this proportion remained stable over time (p = 0.66). Among men with nonmetastatic cancers 24% had tumors with low risk features and the proportion of low risk cancers did not increase over time (p = 0.34).
  
  
  CONCLUSIONS
  Unlike the broader United States population the proportion of disadvantaged men with organ confined, low risk prostate cancer has not been increasing. Thus, while much attention focuses on potential overdiagnosis and overtreatment of men with screen detected prostate cancer, our findings suggest that for low income, uninsured men, underdetection and undertreatment remain significant concerns.
authors.affiliation: Department of Urology, University of California, Los Angeles, California, USA. dcmiller@umich.edu
authors.forename: David C
authors.initials: DC
authors.lastname: Miller
authors.forename: Mark S
authors.initials: MS
authors.lastname: Litwin
authors.forename: Jonathan
authors.initials: J
authors.lastname: Bergman
authors.forename: Sevan
authors.initials: S
authors.lastname: Stepanian
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Connor
authors.forename: Lorna
authors.initials: L
authors.lastname: Kwan
authors.forename: William J
authors.initials: WJ
authors.lastname: Aronson
mesh_terms: D000328:Adult; D001741:Black or African American / Q000706:statistics & numerical data*; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D001294:Attitude to Health / Q000208:ethnology; D002140:California / Q000453:epidemiology; D015331:Cohort Studies; D004522:Educational Status; D006266:Health Education / Q000458:organization & administration; D006801:Humans; D008297:Male; D008403:Mass Screening / Q000639:trends; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D008875:Middle Aged; D020380:Needs Assessment; D009361:Neoplasm Invasiveness / Q000473:pathology*; D009367:Neoplasm Staging; D011203:Poverty; D015995:Prevalence; D011471:Prostatic Neoplasms / Q000453:epidemiology* / Q000473:pathology* / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D012959:Socioeconomic Factors; D016019:Survival Analysis