Prostate Cancer Active Surveillance and Black Men
A recent article in the New England Journal of Medicine suggested most men diagnosed with low to intermediate-risk prostate cancer can delay harsh treatment without hurting their chances of survival. The study's reassuring findings garnered heavy coverage by US news organizations.
As a health educator and writer, I wondered how newly diagnosed men with prostate cancer might process this news. Would they investigate the study's context and whether the conclusions were necessarily applicable to their situations? I was alarmed when a college friend diagnosed with an intermediate-grade prostate cancer tumor just before Christmas told me he hadn't made a follow-up appointment yet. His understanding of the study was he didn't have to do anything yet. My friend is Black and wasn't aware that African American men lead the world in prostate cancer deaths.
It turns out the study was conducted in the UK. Researchers followed 1,643 men newly diagnosed with prostate cancer for up to 21 years. They found the risk of dying from the disease was low regardless if the patients were assigned active surveillance, surgery, radiation, or hormone blockers. The findings are significant because treatment for prostate cancer can result in severe side effects, including incontinence and erectile dysfunction.
The study's setting makes a difference because the UK has a national healthcare system that makes long term continuity of care more feasible. In the US, health insurance benefits are usually tied to work. Specifics, including which doctors you can see, change as people are laid off, switch jobs, or an employer chooses a different insurance carrier. Not having health insurance, changes in insurance status, or being underinsured can delay prostate cancer screening, diagnosis, and treatment, negatively impacting health outcomes.
Something else about the study that concerned me is the authors gave no information on the ethnic or racial demographics of the study's participants. As I alluded to before, African American men have the highest incidence of prostate cancer globally. According to the Centers for Disease Control and Prevention, the incidence rate for Black men is 183 cases per 100,000, compared to 110 cases per 100,000 among white men. Black men are more likely to develop prostate cancer at younger ages and be diagnosed with more aggressive tumors or diagnosed at later stages, leaving them with fewer treatment options. Black men also have a 2.2-fold higher risk of prostate cancer death than White men.
So, does this mean newly diagnosed Black men shouldn't choose active surveillance? No, but the research to support this answer is complicated because African American men have long been under-represented in prostate cancer studies, including active surveillance.
Dr. Howard Parnes, who heads the Prostate and Urologic Cancer division at the National Cancer Institute explains results thus far have shown that most (but not all) studies have reported increased tumor-grade progression among African American men during active surveillance. He says this appears to be due to a greater risk of underestimation of the actual tumor grade in African American men at the start of surveillance. One possible explanation is that African American men may be more likely to have cancers in the anterior region of the prostate gland, which is more difficult to sample with a standard biopsy.
Parnes says NCI researchers have found that Magnet Resonance Imaging or MRI-targeted biopsies led to significantly more upgrading in African American men than in White men. Still, the men who qualified for active surveillance following MRI did just as well with further follow-up. He emphasizes that having tumors progress during active surveillance leads to treatment and doesn't necessarily mean a bad cancer outcome.
Parnes says African American men should not be denied the option of active surveillance since the harms of "over-treatment" are substantial. However, healthcare providers (HCPs) need to know that Black men may benefit particularly from prostate MRI with image-guided biopsies of any abnormalities to reduce the risk of misclassification and enable a more informed decision of active surveillance versus treatment. (Attached below are 2 prostate cancer active surveillance studies)
Furthermore, he says it is vital for all men to adhere to follow-up recommendations regarding subsequent prostate biopsies strictly. Unlike my friend's take, active surveillance doesn't mean not doing anything. It means seeing your doctor frequently, having your doctor follow you closely, and getting frequent scans. I’m happy my friend now has an appointment for the end of the month.
Social Health Research educates and helps keep HCPs up to date on recommendations to close healthcare outcomes gaps for historically underserved populations. Suggestions like the NCI's findings that MRI biopsies may provide more precise tumor grade estimations for Black men with prostate cancer than standard biopsies. We also consider public health education, prevention, and health literacy necessary to maintaining a healthy lifestyle. We stress proactive measures, including regular checkups and screening tests, to help people avoid severe illnesses. We question the parameters and context of reported medical studies to help Americans determine whether new findings apply to their personal health situations.
-Vicky Que, VP of Strategy and Content