Used with permission – http://www.realclearhealth.com/articles/2016/10/17/african_american_men_should_consider_more_aggressive_prostate_cancer_treatment__110170.html
By Crystal Moore
October 17, 2016
Recently, a study published in The New England Journal of Medicine suggested that outcomes of prostate cancer patients who underwent aggressive treatment were no different than those who chose the so-called “watchful waiting” approach for this typically slow-growing cancer.
While those results may be true for patients in general, African-American men might choose the more aggressive approach.
As a pathologist I diagnose prostate cancer almost daily. I know that the majority of my patients will have a good outcome and are more likely to die from a cause unrelated to prostate cancer. However, when I see that my patient is African-American, I know he may not be as fortunate.
African-American men have a higher incidence of prostate cancer, tend to develop a more aggressive version of the cancer and, according the National Cancer Institute, are more than twice as likely to die from the disease as white men. It is not yet clear why African-American men develop prostate cancer more frequently or why death rates are higher, other than to say the reasons are likely multifactorial and due to a combination of genetic differences, lifestyle, nutritional habits and access to and utilization of medical services. For many researchers, like myself, this answer isn’t good enough and it is one we are dedicated to improving.
This is because the study design did not seem to highlight the inclusion of African-American men. In fact, less than 1 percent of the participants were African-American. This is not surprising as traditionally it has been difficult to recruit African-American men into clinical trials and studies. Much of the data in large biomedical studies has a negligible racial composition, even though researchers know drugs affect certain minorities differently. For instance, 75 percent of Pacific Islanders who take certain blood thinners see no effect, Puerto Ricans do not respond well to many common asthma medications, and people of Asian descent, with certain genomic profiles, risk serious side effects if they take one particular epilepsy medication.
Consequently, the results of any study may not necessarily apply to specific populations. For a country with a demographic profile as varied as the United States, correcting the lack of African-American and minority participation in medical trials is a racial disparity that must be addressed if all segments of America’s population are going to benefit from massive government investments in biomedical research. Martin Luther King Jr. stated that “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” And the disparities in the morbidity and mortality of African-American men with prostate cancer are a timely example of this inequality.
There are two other known risk factors for developing prostate cancer aside from race. One is a family history of prostate cancer in close relatives or in relatives diagnosed at an early age. The other risk factor is advancing age with approximately 60 percent of prostate cancer diagnosed in men older than 65. Yet neither of them explains why race is such a large risk factor.
Recent hypotheses suggest that certain genetic factors might account for the greater disparities in how prostate cancer affects African-Americans. Researchers believe variations in the genetic background of certain populations are associated with higher or lower risks of prostate cancer. As such, the DNA changes associated with a greater risk for prostate cancer are found most often in African-American men.
This factor alone does not account for the greater incidence of prostate cancer and the higher mortality rate from prostate cancer in African-Americans. The challenge that my colleagues and I are tackling, and one that will help all prostate cancer patients, is determining indolent (or slow growing) cancers from more aggressive ones. We believe that the prostate tumors in African-American men have distinct genomic profiles that may be used to distinguish aggressive tumors. Being able to understand these genomic variants will help distinguish between the slow growing and aggressive tumors in African-Americans, or any other ethnic population, and will improve treatment protocols significantly for all men.
Developing greater knowledge into which tumors will be aggressive will have a major impact on treatment determinations, including whether or not surgery or radiation is advisable or if watchful waiting and active monitoring are the preferred treatments. However, to make these decisions about the best course of treatment, African-American men must have access to health services and historically, this hasn’t always been the case.
While the passage of the Affordable Care Act has increased access to health insurance and health services for many African-American men, the Kaiser Family Foundation claims more than seven million still do not have health coverage because of the failure to expand Medicaid in many states, including those with large African-American populations. This makes African-American men significantly less likely to receive the regular physical examinations that could help identify prostate cancer early.
Making progress in reducing the impact of prostate cancer in African-American men and reducing the racial disparities that result in a mortality rate more than two times as high as other populations is not unachievable. Researchers are unlocking the science, more African-American men are getting involved in clinical trials and access to health services is increasing slowly. In fact, by recognizing the disparity exists in the first place, we have taken the necessary steps to reduce the impact within African-American communities.
I am often approached by people who have a loved one recently diagnosed with prostate cancer. They ask for information and understanding. They seek reassurance. And usually I am able to inform them that their loved one will not likely reach their demise from this slow-growing cancer. However, when approached by an African-American, I choose my words more carefully, knowing that the risks are greater for these neighbors, fathers, brothers and uncles. Through outreach, education, research and improvements in treatments for more aggressive prostate cancers, I look forward to the day when I can give everyone the same answer, that they can look forward to sharing many happy, healthy years with their loved one.
Crystal Moore, MD, PhD, FCAP, is a member of the College of American Pathologists.