Since the 1990s, prostate cancer death rates have dropped for all men -- most of all for African Americans. That's progress, for sure, but it’s not the full picture.
Black men have a greater risk of getting prostate cancer -- and a more aggressive type -- than white men, says Brandon A. Mahal, MD, a radiation oncologist with the Dana-Farber Cancer Institute. It takes a grim toll: Black men are more than twice as likely to die from the disease.
What's behind numbers like these? And what needs to change? Many things come into play, including access to care, genetics, environment, and lifestyle.
What We Know -- and Don’t Know
“We now have a lot of data about prostate cancer outcomes in black men,” says Kosj Yamoah, MD, PhD, a radiation oncologist at Moffitt Cancer Center. “And this may help us provide better treatment.”
Still, research in African Americans is lacking. In some cases, researchers haven’t even reported the race or ethnicity of men in their prostate cancer studies. When they have, fewer than 5% of those who’ve taken part are black.
You can partly trace this low participation to what’s required to enroll in a trial, such as lab test results. “Normal lab results” are often based on a group that’s not diverse, Mahal says. But what’s “normal” can differ across race, gender, and age. And when studies are done mostly in white people, it’s hard to tell if the results apply to others.
Where Differences Arise
Black men don’t just get this disease more often than white men. They also tend to get it at an earlier age. And their cancer tends to spread more quickly. “A prostate cancer that starts at age 40 and spreads by age 50 is unlike one that shows up first at age 70 -- one you never have to worry about,” says Yamoah.
Genetics also comes into play with prostate cancer -- more so than for any other type of cancer. “Part of the difference in prostate cancer rates -- and, therefore, deaths -- may be due to these inherited factors,” says Lorelei Mucci, ScD, an associate professor of epidemiology at the Harvard School of Public Health.
Screening, Active Surveillance, and Biopsies
Early detection is important for everyone with prostate cancer. But Mucci says black men face unique barriers when it comes to diagnosis.
One hurdle for black men is lack of access to insurance and medical care, Yamoah says. Another is the fact that their tumors tend to start sooner and spread faster. Even when their cancer is the slow-growing (low-grade) type, black men have twice the risk of death as that of other races, although it’s still small.
Screening can save more black lives than it can for those at lower risk. When prostate-specific antigen (PSA) screening tests began in the 1990s, death rates fell the most for black men. Early -- and frequent -- screening is critical because of the strong link between midlife PSA levels and the risk for black men of getting aggressive prostate cancer.
These are the American Cancer Society guidelines for higher-risk groups:
- Start PSA at age 45 for African Americans and men who have a father or brother who had prostate cancer when they were younger than age 65.
- Start PSA at age 40 for men with more than one close relative who had prostate cancer when they were younger than age 65.
For white men whose PSA levels are above normal, doctors usually choose active surveillance, or “watchful waiting.” With repeat PSA tests, rectal exams, and biopsies, they can check for signs that the cancer is growing. This approach isn’t used as much with black men because the risks are much higher.
That may be changing. MRI-guided biopsies -- and genomic tests -- can now help rule out a cancer that is spreading more quickly. Taking more tissue samples with a saturation biopsy is another option. This type of biopsy takes 20 or more tissue samples in one test, compared to the usual 12 -14.
If you’re a black man, the biopsy technique is crucial. That’s because your tumor will tend to sit in the front part of the prostate, says Mahal. “This zone tends to harbor more aggressive cancers, but standard biopsy techniques often miss them.”
“If these newer tests point to a low-risk cancer, I think it’s safe to then use active surveillance,” says Mahal. Studies that follow patients that take this approach will help doctors have a better idea.
Treatment Delivery and Response
“We know that black men have delayed diagnoses -- and, therefore, treatment,” Mucci says. “They also tend to get different types of treatment, and their access to care is different,” she says. Yamoah cautions that “We’re not asking doctors to treat black men with prostate cancer differently … we need to treat [people] based on their biology.”
We still don’t know whether certain prostate cancer treatments work as well for black men, Mucci says. But Mahal points out that “In radiation trials where patients had the same disease status and equal access to care, black men actually had a better prostate cancer survival rate than others.” He adds that their overall death rates were higher, but that this may have been due to having more than one illness.
What You Can Do
- Push for early, frequent prostate cancer screening tests.
- Ask your doctor about tests that may better spot prostate cancer in black men.
- Find out which tests and treatment your insurance covers.
- Learn about your treatment options. Partner with your doctor to get the very best results you can.
- Enroll in a prostate clinical trial.