Ross, Schaeffer, and Sundi: In this study, "African American men had
threefold higher rates of more advanced, aggressive disease," although
their cancer seemed at first to be low-risk.
If you are an African American man, you should take prostate cancer very seriously because, unfortunately, your life may depend on it. No other group of men in the world shares your risk of getting prostate cancer, of getting the kind that needs to be treated, of having it diagnosed at a later stage, and of dying from it. Now, important research by Brady investigators has shown that even the "best" kind of prostate cancer – the kind that seems to be very low-risk, the kind that could be treated with active surveillance – may not be as benign in African American men.
"Active surveillance is a highly successful management strategy for men with very low-risk prostate cancer," says urologist Edward Schaeffer M.D., Ph.D. "But African American men are more likely to be diagnosed with, and die from, prostate cancer." And so, Schaeffer has been wondering, "is conservative management of prostate cancer in African American men a wise choice?"
To find out, Schaeffer, along with colleagues including H. Ballentine Carter, Debasish Sundi, and Ashley Ross, recently studied 1,801 men who met the National Comprehensive Cancer Network’s criteria for very low-risk prostate cancer. These men were candidates for active surveillance but elected to undergo immediate prostatectomy instead. The groups consisted of 256 African American men, 1,473 white men, and 72 men of other races. The team investigated pathologic and cancer-specific outcomes in these men, and the results were striking: "Surprisingly," says Schaeffer, "African American men had threefold higher rates of more advanced, aggressive disease, which resulted in much poorer outcomes, compared to white men." In other words, even though these men had been considered at very low
risk, their cancer turned out to be more aggressive and more extensive than the initial biopsy and physical exam had suggested.
Barely a tenth of the men in most
active surveillance programs are
black, although the results are
generalized as applying to all
men equally. But prostate cancer,
even the "very low risk" kind, is
different in African American men.
This work, published in the Journal of Clinical Oncology, prompted Schaeffer to team up with renowned prostate pathologist Jonathan Epstein for further investigation. In studying the prostatectomy specimens from these men, Epstein found that, compared to Caucasian men, the tumors in African American men were larger, of higher grade, and more likely to appear in harder-to-diagnose areas of the prostate. These findings, published in the Journal of Urology, showed that African American men had high-grade cancers at the top of the prostate – an area that is farthest from the rectum – nearly 60 percent of the time .
High-grade cancers tend to form in different areas of the
prostate in white and black men: Nearly 60 percent of
high-grade cancers in black men were at the top of the
prostate – farthest away from the rectum, and hardest to
reach in a needle biopsy.
"This is an area of the prostate that is particularly difficult to reach with standard biopsy approaches," says Sundi, the lead author on the studies, "and this may explain why the more aggressive cancers were missed more often in black men." It may be, Schaeffer adds, "that adding special biopsy procedures or prostate imaging with MRI could help identify these more aggressive anterior tumors. This work also suggests that there may be biologic differences in the prostates of African American men that drive these tumors to develop in a different location, and this will be a key area of our research in the future."
Back to Schaeffer’s original question: Is active surveillance safe for African American men? Given these results, probably not. "The favorable outcomes achieved for men in active surveillance are based on studies that under-represent African American men." In fact, barely a tenth of the men in most active surveillance programs are black, yet the results are generalized as applying to all men equally. Because "very low-risk" cancers in African American men seem different from those in other men, Schaeffer believes that "we need race-specific recommendations" for the treatment of very-low risk cancer. "African American men need to understand these risks when they choose treatment for their prostate cancer. Specifically, they need to know that if they decide on active surveillance, aggressive cancer may be missed."