Addressing prostate cancer’s racial disparity starts with you

Several decades of data show that Black men are less likely to be screened and treated for prostate cancer than their white counterparts. In this interview, Kelvin A. Moses, MD, PhD, discusses the reasons for these disparities, potential genetic, cultural, and environmental factors, new data showing improved outcomes in Black men receiving certain treatments, and how practicing urologists can address prostate cancer disparities. Dr. Moses is associate professor of urology at Vanderbilt University Medical Center, Nashville, TN.

Dr. Moses was interviewed by Urology Times Editorial Consultant J. Brantley Thrasher, MD, executive director of the American Board of Urology, Charlottesville, VA.

Why do you think there’s still a large disparity between African-American and white men when it comes to prostate cancer survival?

It’s been persistent for decades, and there are a lot of factors that go into it. During the PSA screening era-from the late 1980s to 2012 or so-the gap did narrow some. That was likely due to some increased screening and better treatments. But overall, there’s been a disparity in screening, and among men who are diagnosed, a disparity in treatment; Black men are less likely to get treated overall. Insurance, socioeconomic status, and cultural factors all play a role, but the lion’s share of the disparity comes from the factors that we as urologists have some control over.

One of my African-American patients told me that reaching out to the wives of patients to encourage screening is important. What are your thoughts about that?

I really support that, and I think it’s very important. It’s an effort that I’ve done, as have Dr. Isaac Powell in Detroit, Dr. Willie Underwood in Buffalo, and Dr. Mark Litwin in Los Angeles, among many others. One of the best methods of community engagement is to involve men who are at risk, as well as their partners and loved ones. It’s very effective.

Bringing in the wives and partners helps because sometimes men are a little fearful or resistant, and having the people who love you encouraging you to seek out health information is very important. Sometimes there is a barrier or a mental hurdle about visiting a large academic center or hospital, and that outreach breaks down the barrier so you can start a conversation about screening.

Do you think there is still a bit of skepticism-a “Tuskegee effect”-among African-American men and a perception that “I’m being experimented on”?

Absolutely. There’s a cultural memory that’s attached not only to Tuskegee, but also to the history of separate and unequal facilities, segregated hospitals, and not being able to get to a doctor until it’s too late. There’s been research on perceptions about surgery and spreading cancer, and that perception largely comes from people who do not have access to appropriate health care and can only obtain care on an emergent basis. By the time they get to surgery or even imaging, it’s too late, and it seems as though the surgery was the problem when really it was the access and the barriers that preceded it.

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As my generation is now entering our 40s and 50s and our parents are moving on, we’ve been able to dispel some of the mythology, but barriers to adequate health care definitely remain.

Don’t we still see, though, some real disparities, even in an equal-access system like the military or the VA?

You do, but it’s not as glaring a difference. Dr. Steve Freeland’s group has published several papers showing at least almost equivalent outcomes, maybe a little worse in Black men, and that’s where the genetic/biologic aspect comes into it. A study I did with Dr. Karim Touijer examined younger men who underwent surgery for prostate cancer and the pathologic outcomes were nearly similar, with slightly higher risk of biochemical recurrence. But overall, equal treatment can yield almost equal outcome. The VA and states that have participated in Medicare exchanges through the Affordable Care Act can approach much more equitable outcomes.

We’ve often heard data quoted that African-American men present with prostate cancer at an advanced stage and an earlier age. Do you still think that that’s the case, and if so, how do you counsel men when you talk to them about prostate cancer?

It absolutely is the case, and the population-level data support that. SEER data have shown that Black men present at an earlier age and have higher risk and higher grade disease. The National Cancer Database and CaPSURE show similar findings.

I have recommended that we follow what are now the revised USPSTF guidelines or NCCN guidelines and start screening for prostate cancer earlier in Black men, just like we do in patients with first-degree relatives. Specifically, I believe screening should start somewhere around age 40 or 45.

In addition, there is an important aspect to consider known as environmental racism, where there are structural aspects of our society where Black and poor populations are more likely to live near an oil refinery or Superfund site or chemical plant. Those increase the risk of cancer, there’s no doubt about it. Environment does play a role, and genetics plays a role.

Taking all that together, I encourage men to be vigilant about getting screened for prostate cancer earlier, particularly if they have a family history. So many men who come into my clinic and tell me their dad died of bone cancer; it is more likely prostate cancer that spread and they just didn’t know it. 

Next: "It all goes back to communication and breaking down the barriers."I have some men tell me, “I don’t mind getting a blood test. I do not want to have a rectal exam.” Do you hear that?

I’ve had men say they’d rather die than have me stick my finger in their rectum, and I tell them, “You just might.” It all goes back to communication and breaking down the barriers. I tell men, the way they came into the office is how they’re going to leave. I explain that this exam isn’t for our fun but for their health. In some cases, men haven’t seen the doctor since they tried out for sports in high school, and now that they’re 50 or 55 years old, they’re back in the health system. We have to break down the male ego to get over that mental hurdle.

It’s been shown recently that obesity, which is rampant in the United States, is associated with 13 cancers, including prostate cancer. Is there a possibility that may play a role in the disparity?

I don’t know if there’s such a tremendous difference in the proportion of Black versus white men who are obese. Obesity is an inflammatory state, and cancer is a disease of inflammation. I published a paper several years ago that showed individuals with a negative balance of omega-3 to omega-6 fatty acids in the blood are more likely to have higher grade prostate cancer on biopsy. There are some data to suggest that obesity has a diluting effect on PSA, meaning that a slightly elevated PSA may actually be even higher in a normal weight person.

What do you see as other contributors? Are there genetic abnormalities?

In terms of genetics, prostate cancer is different than cystic fibrosis, for example. In cystic fibrosis, a specific gene causes this disease, whereas prostate cancer involves a whole host of genes interacting. However, the 8q24 gene and CYP3a4 mutations are associated with higher risk disease and are more highly expressed in Black men. The genes that we’re more familiar with, such as TMPRSS2-ERG, may be more highly expressed in white men. Another gene, ROBO1, has been shown to be associated with metastatic disease and is much more highly expressed in African-Americans. Dr. Christopher Warlick from Minnesota gave an excellent summary of this at a 2019 AUA plenary session.

There are definitely gene targets that could be evaluated for risk of disease progression. But again, we’re probably looking at multiple targets.

In the world of precision medicine and artificial intelligence, do you think there will come a time when we can look at a particular African-American man and determine his risk of dying from prostate cancer? 

I think so. But first we need more information from biobanked specimens from Black men. Most clinical trials that collect tissue or serum include very few Black men, and most active surveillance databases that have biopsy tissue have, at most, 3% or 4% of tissue from Blacks. Before we can identify specific targets, we’ll need a pool to confirm the significance of that subset of genes. We need to increase the enrollment of Black men in clinical trials, and we need to have a robust repository of tissue and serum from Black men. 

What else do you think the field of urology or urologic oncology can do to try to close that gap?

It’s all about education. We talk about patients’ literacy and familiarity with their health care, but physicians need education, too. We need to know how to talk with patients and have cultural competency. We also need to diversify. Just as we have emphasized the need for more women in urology, we need more Black faculty and residents in urology, as well as Hispanics. Some of the disparity we have seen in Black men is now being seen increasingly in Hispanic men.

What I’ve seen in my practice is that African-American men will generally respond much better to African-American physicians. It seems that perhaps the level of attention is not quite the same with white physicians as it is with African-American physicians. Would you agree?

Absolutely, and the literature bears that out. Plenty of studies show that non-white patients who have an ethnically concordant physician have better outcomes and greater satisfaction from the interaction. This holds true in diabetes, blood pressure, and cancer. If you’re part of a smaller proportion of the population and you’re not well represented, but the person across from you looks like you, there is an increased comfort level. I see it in my patients’ face. There’s an automatic level of understanding and communication that happens that I think is critical when making the right treatment decisions. Conversely, white patients receive the same high-quality care and satisfaction regardless of the race/ethnicity of the physician.

What can the average practicing urologist do about the racial disparity in prostate cancer and help close that gap in the community?

Know the literature. We have 40 years of descriptive analysis showing racial disparities. At this point, what more can we describe that will prove there is a problem? Physicians who truly want to address these issues need to get out in the community. Regardless of your race, if you are authentic, visible, and make key alliances with stakeholders in the community, you will be effective.

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I would caution against screening events just for the sake of screening, unless you’re going to have follow-up for the patients so they can get appointments and undergo biopsies if needed. That’s what the USPSTF guideline panel emphasizes: shared decision-making and making an educated choice.

Do you have any other take-home messages? 

We need to believe the data. Again, we have over 40 years of descriptive data showing disparities linked to screening and treatment. We also have new data showing improved outcomes in Black men in certain instances. For example, the IMPACT study and PROCEED registry showed greater overall survival improvement in Black versus white patients after treatment with sipuleucel-T. Additionally, there are data showing Black men have better survival outcomes with enzalutamide and abiraterone acetate.

Physicians examined the data showing that opioids were a serious problem and that we were part of it. We have performed population-level research, created postoperative pain pathways, modified our behaviors, and modified patient interaction and how we manage pain. This proves that we as a field are able to identify a problem and come up with solutions in a timely manner. Let’s do the same thing with prostate cancer in Black men.

The AUA has had the opportunity to use a couple of champions of prostate cancer who are African-American men that were professional football players. Do you think those campaigns are effective?

I think so. There’s nothing wrong with putting a familiar face with an important issue. It’s what women have been doing much more smartly for a long time. In addition, having an NFL player is great, but it’s also important to have somebody from the community that people know-the pastor, the mayor, whoever they see on a daily basis-because it’s easy to idolize somebody and then put them off. But sometimes that person sitting next to you is just as impactful.

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