What are your thoughts on recent studies regarding AS and radiation in African-American men?

Editor's Note: For this month’s installment of “Speak Out,” urologists were asked to discuss recent studies indicating African-American men with prostate cancer may be put on active surveillance without suffering complications and that they respond to radiation and some chemotherapy better than Caucasian men. The research discussed includes the scientific meeting presentations “Overall survival by race in chemotherapy-naïve metastatic castration-resistant prostate cancer (mCRPC) patients treated with abiraterone acetate or enzalutamide” (presented at the 2019 GU Cancers Symposium), “Androgen receptor activity and radiotherapeutic sensitivity in African-American men with prostate cancer: A large scale gene expression analysis and meta-analysis of RTOG trials” (2018 ASTRO annual meeting), “Prostate cancer upgrading and upstaging in a multicenter prostate cancer registry” (2018 AUA annual meeting), and a paper published in the Journal of Clinical Oncology (2019; 37:403-10).

“If you start from the premise that African-American men have more aggressive prostate cancer, you can break the reasons down into socioeconomics and biology. These studies basically account for socioeconomic status and for staging. If everybody is on the same playing field, according to one study, radiation is a viable option for African-American men, for at least one particular gene expression. Radiation can give them a better response than Caucasian men.

In the real world, however, the playing field is not even, because black men aren’t getting screened. They show up with metastatic disease. If you can get them screened, this study shows they can do just as well, if not better than whites.

It’s the same with active surveillance. If someone is in an active surveillance protocol, they’ve already been screened and qualified for active surveillance. So they’ll do just as well.

People took it for granted that the black men did worse with prostate cancer with no dissection of why. Some of it was just believing that there had to be something different genetically. Maybe that still is likely, but this study dispels the idea that it’s just biology that causes African-American men to have worse cancer.”

Michael Bivins, MD / Birmingham, AL

Next:"I’m hopeful these studies will lead to more men getting screened earlier."

“In general, African-American men have more aggressive disease. So here’s a treatment which is actually no treatment: active surveillance. Data suggests African-American men are likely to progress on active surveillance, but that doesn’t mean it shouldn’t be offered. It just means they should be followed closely-not that it’s not worth trying.

We’re also seeing that when African-American men are matched stage-for-stage, grade-for-grade, they do similarly after surgery and with radiation as white men. When you get to late-stage chemo, there is data they’re actually doing better. That’s great, but it opens up a million questions as to why. 

From a clinical perspective, we must consider their Gleason, their PSA, and their genomics and come up with a treatment plan. Race shouldn’t really figure into it.

Socioeconomics may contribute to people waiting too long to come in, but even in equal-access centers, black men are diagnosed at younger ages than white men. It’s not simply waiting too long. Socioeconomics clearly is a factor. Being poor is clearly a stress factor, particularly in the United States, and we know stress can increase cancer risk and aggressiveness. So a lot of factors are in play. 

I’m hopeful these studies will lead to more men getting screened earlier. They’re more likely to have aggressive disease, but if it’s caught early the outcomes are identical to what we see in white men. That’s the silver lining about this.”

Stephen Freedland, MD / Los Angeles

Next: “The studies are a bit controversial, and other big-data studies of large databases across Medicare and the country clearly show that African-American men are still more severely affected by prostate cancer."

“The studies are a bit controversial, and other big-data studies of large databases across Medicare and the country clearly show that African-American men are still more severely affected by prostate cancer.

There are some questions why that is-possibly the biology of the disease-where prostate cancer actually starts. In African-American men, it often occurs in the apex of the prostate. That’s a tougher area to biopsy. We may miss cancers more often than in other races. So I take new studies that show active surveillance is a more likely scenario for African-Americans with a grain of salt. 

Until we have better information on genetic makeup that correlates with the biology of the disease, we still have to be vigilant in our approach to prostate cancer in African-American men.

Many studies still stand with the fact that African-American men are also more likely than not to have more aggressive disease. Certainly some patients have a benign course, but we have to monitor these patients very closely.

As for the treatment studies, we know certain men respond to chemotherapy, others to radiation. So it makes sense that some subtypes of population, whether African-American or other races, are going to respond to specific treatments better than others. But until we have a good genetic profile of which cancers respond better, we don’t have much choice except to continue doing what we’re doing.”

Michael Palese, MD / New York

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