title: National Economic Conditions and Patient Insurance Status Predict Prostate Cancer Diagnosis Rates and Management Decisions.
abstract: The recent Great Recession from December 2007 to June 2009 presents a unique opportunity to examine whether the incidence of nonpalpable prostate cancer decreases while conservative management for nonpalpable prostate cancer increases during periods of national economic hardship.
  
  
  
  We derived rates of national monthly diagnosis and conservative management for screen detected, nonpalpable prostate cancer and patient level insurance status from the SEER (Surveillance, Epidemiology and End Results) database from 2004 to 2011. We derived monthly statistics on national unemployment rates, inflation, median household income and S&P 500® closing values from government sources. Using linear and logistic multivariable regression we measured the correlation of national macroeconomic conditions with prostate cancer diagnosis and treatment patterns. We evaluated patient level predictors of conservative management to determine whether being insured by Medicaid or uninsured increased the use of conservative management.
  
  
  
  Diagnosis rates correlated positively with the S&P 500 monthly close (coefficient 24.90, 95% CI 6.29-43.50, p = 0.009). Conservative management correlated negatively with median household income (coefficient -49.13, 95% CI -69.29--28.98, p <0.001). In a nonMedicare eligible population having Medicaid (OR 1.51, 95% CI 1.32-1.73, p <0.001) or no insurance (OR 2.27, 95% CI 1.93-2.67, p <0.001) increased the use of conservative management compared to that in men with private insurance. As indicated by a significant interaction term being diagnosed during the Great Recession increased the Medicaid insurance predictive value of conservative management (OR 1.30, 95% CI 1.02-1.68, p = 0.037).
  
  
  
  National economic hardship was associated with decreased diagnosis rates of nonpalpable prostate cancer and increased conservative management.
authors.affiliation: Pritzker School of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Adam B
authors.initials: AB
authors.lastname: Weiner
authors.affiliation: Department of Public Health Sciences, University of Chicago, Chicago, Illinois; Section of Hematology/Oncology, Department of Pediatrics, University of Chicago, Chicago, Illinois.
authors.forename: Rena M
authors.initials: RM
authors.lastname: Conti
authors.affiliation: Section of Urology, Department of Surgery, University of Chicago, Chicago, Illinois. Electronic address: seggener@surgery.bsd.uchicago.edu.
authors.forename: Scott E
authors.initials: SE
authors.lastname: Eggener
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D019468:Disease Management; D006801:Humans; D015994:Incidence; D007348:Insurance, Health / Q000706:statistics & numerical data*; D008297:Male; D017057:Medically Uninsured; D008875:Middle Aged; D011471:Prostatic Neoplasms / Q000175:diagnosis / Q000191:economics* / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors; D018426:SEER Program; D014481:United States / Q000453:epidemiology
keywords: SEER program; United States/epidemiology; early detection of cancer; prostatic neoplasms; watchful waiting