Prostate cancer in black men

Black men have significant differences in incidence, presentation and outcome of prostate cancer compared to other racial groups. Multiple factors play a role including genetic differences and social determinants of health. Understanding these differences helps us to create better healthcare strategies for black men.

Prostate cancer (PC) is the most common cancer diagnosed in men in SA, surpassing basal cell cancer in the latest National Cancer Registry cancer report (2017).¹ PC is the second most common cause of death through a malignancy in SA, after lung cancer.²

Internationally it has been found that black men with PC have worse outcomes than other population groups. In the USA, racial disparities in PC survival present a serious challenge. Black men, who are referred to as African American* (AA) men in the USA, have a nearly 1,8 times higher population-level mortality rate than white men.³ Among AA men younger than age 65, the PC mortality rates are nearly three times greater than that of white men younger than age 65.⁴ 

South African data

Looking at SA data, there are similarities in the racial disparities found in PC. A 2011 study found that black men presented with higher grade and stage disease and higher serum PSA; received potentially curative treatment less often; and had a shorter follow-up than the white and coloured groups.⁵ Another 2018 study found that when comparing black patients as a group to the coloured, white and Asian patients, they found that black patients had higher PSA values; were more likely to be diagnosed with cancer; were more likely to present with locally advanced cancer; and were more likely to have high-grade disease.⁶

Researchers in the USA have looked at different factors like social determinants of health, treatment and genetic factors to understand these disparities. While the research among AA men isn’t directly translatable to SA context, it does give us food for thought and opportunities for further research in SA population groups. 

Screening recommendations

Considering that several aspects of PC are different in white and AA men, the argument can be made that screening recommendations in the USA should be differentiated according to race.⁷ The United States Preventative Services Task Force screening recommendations for PC clearly identifies AA men as having a higher risk for PC, needing informed decision-making on screening. 

Similarly in SA, the proposed South African Prostate Cancer Guidelines draft (2017) recommend that informed patient-based screening is recommended in males from the age of 40 in black patients and from the age of 45 years in all other males.⁸

Knowledge

One of the reasons given for poorer outcome among black men in the USA is later presentation of PC. One review found that many AA men have inadequate knowledge of PC and early detection. Studies indicate that knowledge of PC is particularly low among older, less-educated, lower-income, and unmarried men, along with those who lack a regular physician or health insurance.⁹

In terms of communicating PC information, one study found that black men prefer interpersonal communication for PC information; trusted sources included personal physicians, clergy, and other community leaders, family (especially spouses) and PC survivors.¹⁰ 

Women are important role players in PC awareness among black men. Better understanding women’s supportive roles is important in developing strategies for PC.¹¹

Continuity of care (COC) also plays a role in PC outcomes. For AA patients with advanced PC, better COC was associated with a reduction of 22% in all-cause mortality, 26% in PC specific mortality compared to white patients. Improving COC can help reduce some of the disparity in short- and long-term outcomes.¹²

Genetics

There is considerable research into the genetic profiles of high-risk populations, such as black men, to identify genetic variants that import higher risk for PC. 

Germline testing found that family history of breast or ovarian cancer predicted pathogenic variants in white but not AA men, highlighting the limitations of family history in AA men and the importance of personal history to guide germline testing in AA men.¹³ 

The impact of BRCA1 and BRCA2 on PC in AA men remains unknown due to the high frequency of variants of unknown significance.¹⁴

PC disproportionally affects African and AA men. The Men of African Descent Carcinoma of the Prostate Network (MADCaP) has developed a custom genotyping platform, collecting data from Ghana, Nigeria, Senegal, and South Africa using the MADCaP Array.¹⁵ Genotyping tools, such as the MADCaP Array, will enable novel cancer associations to be discovered in historically understudied African populations.

Other factors

Other factors identified associated with more aggressive disease in black men are inflammation, vitamin D deficiency and smoking.^{16, 17,18}

While smoking hasn’t been an established risk factor for PC, there is evidence that among black men there is a higher risk of biochemical recurrence, PC mortality, and metastasis among current smokers.¹⁸ 

Aspirin use and statin use have both been found to reduce the risk of biochemical recurrence among AA men with PC.^19,20

References

1. National Cancer Registry N. Cancer in South Africa Full Report 2017 [Internet]. 2017 [cited 2021 Sep 8]. Available from: https://www.nicd.ac.za/wp-content/uploads/2020/12/NCR_2017_Final_02dec2020.pdf
2. Babb C, Urban M, Kielkowski D, Kellett P. Prostate Cancer in South Africa: Pathology Based National Cancer Registry Data (1986–2006) and Mortality Rates (1997–2009). Moul J, editor. Prostate Cancer [Internet]. 2014;2014:419801. Available from: https://doi.org/10.1155/2014/419801
3. Mahal BA, Gerke T, Awasthi S, Soule HR, Simons JW, Miyahira A, et al. Prostate Cancer Racial Disparities: A Systematic Review by the Prostate Cancer Foundation Panel. European Urology Oncology [Internet]. 2021; Available from: https://www.sciencedirect.com/science/article/pii/S2588931121001462
4. He T, Mullins CD. Age-related racial disparities in prostate cancer patients: A systematic review. Ethnicity & Health. 2017 Mar 4;22(2).
5. Heyns CF, Fisher M, Lecuona A, van der Merwe A. Prostate cancer among different racial groups in the Western Cape: Presenting features and management. South African Medical Journal. 2011 Apr 4;101(4).
6. Dewar M, Kaestner L, Zikhali Q, Jehle K, Sinha S, Lazarus J. Investigating racial differences in clinical and pathological features of prostate cancer in South African men. South African Journal of Surgery. 2018;56(2).
7. Shenoy D, Packianathan S, Chen AM, Vijayakumar S. Do African-American men need separate prostate cancer screening guidelines? BMC Urology. 2016 Dec 10;16(1).
8. Anderson D, Barnes R, Bida Meshack, Bigalke M, Bongers M, Chetty P, et al. South African Prostate Cancer Guidelines 2017 (Draft Report) [Internet]. 2017 [cited 2021 Sep 8]. Available from: https://prostate-ca.co.za/wp-content/uploads/2017ProstateGuidelinesDraftVersion2016.pdf
9. Coughlin SS, Vernon M, Klaassen Z, Tingen MS, Cortes JE. Knowledge of prostate cancer among African American men: A systematic review. The Prostate. 2021 Feb 23;81(3).
10. Walsh-Childers K, Odedina F, Poitier A, Kaninjing E, Taylor G. Choosing Channels, Sources, and Content for Communicating Prostate Cancer Information to Black Men: A Systematic Review of the Literature. American Journal of Men’s Health. 2018 Sep 25;12(5).
11. Bergner EM, Cornish EK, Horne K, Griffith DM. A qualitative meta-synthesis examining the role of women in African American men’s prostate cancer screening and treatment decision making. Psycho-Oncology. 2018 Mar;27(3).
12. Jayadevappa* R, Malkowicz SB, Guzzo T, Chhatre S, Wein A. MP41-15 ASSOCIATION BETWEEN CONTINUITY OF CARE AND SHORT AND LONG-TERM OUTCOMES IN ADVANCED PROSTATE CANCER PATIENTS. Journal of Urology. 2019 Apr;201(Supplement 4).
13. Ledet EM, Burgess EF, Sokolova AO, Jaeger EB, Hatton W, Moses M, et al. Comparison of germline mutations in African American and Caucasian men with metastatic prostate cancer. The Prostate. 2021 May;81(7).
14. Brown C, McDonald J, Abbas M, Dunston G, Kanaan Y, Ricks-Santi L. Abstract B22: BRCA1 and BRCA2 mutational spectra in African American men with prostate cancer. In: Epidemiology, Lifestyle, and Genetics. American Association for Cancer Research; 2016.
15. Lachance J, Harlemon M, Kachambwa P, Ajayi O, Kim M, Adams M, et al. Abstract 2410: Development of a custom genotyping platform and genetic prediction of prostate cancer risks in sub-Saharan Africa. In: Epidemiology. American Association for Cancer Research; 2019.
16. Nelson S, Batai K, Ahaghotu C, Agurs-Collins T, Kittles R. Association between Serum 25-Hydroxy-Vitamin D and Aggressive Prostate Cancer in African American Men. Nutrients. 2016 Dec 28;9(1).
17. Powell IJ, Chinni SR, Reddy SS, Zaslavsky A, Gavande N. Pro-inflammatory cytokines and chemokines initiate multiple prostate cancer biologic pathways of cellular proliferation, heterogeneity and metastasis in a racially diverse population and underlie the genetic/biologic mechanism of racial disparity: Update. Urologic Oncology: Seminars and Original Investigations. 2021 Jan;39(1).
18. Hsu P-C, Stahr S, Brazeal C, Fontham EH, Su LJ. Abstract PO-201: Smoking as a risk factor for the aggressive prostate cancer for African-American men from the North Carolina–Louisiana Prostate Cancer Project (PCaP). In: Poster Presentations – Proffered Abstracts. American Association for Cancer Research; 2020.
19. Smith CJ, Jordan S, Dorsey TH, Mann D, Loffredo CA, Bowman E, et al. Abstract 1776: Aspirin use among African American men reduces prostate cancer risk: Findings from the NCI-Maryland Prostate Cancer Case-Control study. In: Epidemiology. American Association for Cancer Research; 2016.
20. Khan S, Drake B. Abstract C009: Post-diagnostic statin and metformin use and risk of biochemical recurrence risk among Black and White men diagnosed with prostate cancer at the Veterans Health Administration. In: Poster Presentations – Proffered Abstracts. American Association for Cancer Research; 2020.

*The term African American (AA) has been used as per the studies referenced.

This article is sponsored by Ferring Pharmaceuticals. The content and opinions expressed are entirely the medical expert’s own work and not influenced by Ferring in any way.

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