This story was originally published in April of 2019.
Cancer does not discriminate, except when it does. Prostate cancer takes a harsher toll on Black men than other American men, including other men of color. What is the cause of this discrepancy, and what can be done about it?
Philip Kantoff, Chair of Memorial Sloan Kettering’s Department of Medicine, talks about the reasons for this disparity. He offers insights into whether Black men — and their doctors — should change the way they approach prostate cancer screening and treatment. These are four main points to consider:
1. Black men both get and die from prostate cancer at a higher rate. The reasons are complex and unclear.
“Black men are 50% more likely to develop prostate cancer in their lifetime and twice as likely to die from the disease,” Dr. Kantoff says.
It is difficult to untangle the various factors that might affect the risk and outcome of prostate cancer, Dr. Kantoff explains. “Prostate cancer in Blacks tends to have biological characteristics associated with more aggressive disease,” he says. “There is evidence suggesting that this is partly related to inherited genetic factors.”
He points out that in addition to differences in tumor biology, the higher risk may be tied to disparities in environment and behavior. This could include social stress or more exposure to cancer-causing pollutants. Smoking, poor diet, and lack of exercise, which can cause obesity, may also have effects. Disparities in outcome could be affected by differences in when the cancer is diagnosed and how the men are treated after diagnosis.
2. Black men should be screened for prostate cancer more proactively.
Given the higher risk of developing and dying from prostate cancer, Black men are more likely to be saved by screening, Dr. Kantoff says. The main prostate cancer screening tests are a digital rectal exam, in which a doctor checks for swelling and inflammation, and a PSA test, which measures the level of prostate specific antigen (PSA) in the blood.
Dr. Kantoff explains that a calculation commonly used in the context of screening is: How many men need to be screened in order to save one life? “Theoretically,” he says, “among Black men, that number should be lower.” Screening guidelines have been based on studies that included very few Blacks, so they may underestimate the screening benefit for this group. Overall, Blacks may need earlier and more frequent screening than the general guidelines would suggest.Back to top
3. Black men and their doctors should be more cautious about active surveillance.
Active surveillance is an approach in which low-risk prostate cancer is not treated with surgery or radiation therapy. Instead, it is monitored very closely for any signs of change over months or years. Active surveillance is increasingly the treatment option of choice for low-risk prostate cancer. Many men embrace this approach because the side effects of treatment, usually surgery or radiation therapy, can be significant.
Black men, however, are more likely to develop more-aggressive prostate cancer. Because of that, Dr. Kantoff maintains that active surveillance may be less appropriate for many Black men. As with screening guidelines, there is little evidence to provide guidance one way or the other. Blacks have been underrepresented in active surveillance studies as well.
“Having said that, I think some Black men could benefit from active surveillance,” Dr. Kantoff says. “This question needs to be studied more before we can come to firm recommendations.”Back to top
4. Large research studies are seeking participants to help understand prostate cancer in Blacks.
In 2018, the National Cancer Institute and Prostate Cancer Foundation launched a large-scale research effort to study underlying factors that put Black men at a higher risk for the disease. The five-year study is called RESPOND (Research on Prostate Cancer in Men of African Ancestry: Defining the Roles of Genetics, Tumor Markers, and Social Stress). The study will enroll 10,000 Blacks with prostate cancer. Those interested in participating can contact the study’s leaders to learn more.
Another study led by Dr. Kantoff and colleagues is called IRONMAN (International Registry to Improve Outcomes in Men With Advanced Prostate Cancer). It is enrolling 5,000 men with advanced prostate cancer from diverse populations to look at genetic differences as well as different treatment patterns across the groups.
“A lot of researchers have been studying this topic, but we don’t have solid answers yet, so large studies should be very valuable,” Dr. Kantoff says.Back to top