African American Men Face Higher Risk of Aggressive Prostate Cancer, but Not Necessarily Death

African American men may face a greater incidence of prostate cancer progression and definitive treatment, but new research suggests those increases do not translate to an increased risk of metastasis or death.

According to a new study published in JAMA,¹ nearly 6 in 10 (59.9%) African American men with low-risk prostate cancer experienced disease progression after a median follow-up of 7.6 years, compared with 48.3% of non-Hispanic White men. Similarly, 54.8% of African American men received definitive treatment during the study’s time frame, compared to 41.4% of non-Hispanic White men.

The idea that African Americans face a greater likelihood of aggressive prostate cancer is not new. Though most cases of prostate cancer are considered low-risk and are dealt with through active surveillance rather than immediate treatment, corresponding author Brent S. Rose, MD, of UC San Diego Health, and colleagues wrote that there is concern within the oncology community that African American men might face a sufficiently higher risk of progression to render them poor candidates for active surveillance.

In an effort to calculate the potential risk (or lack thereof), Rose and colleagues conducted a retrospective cohort study of men in the US Veterans Health Administration (VHA) Health Care System. The 8726 patients in the study were diagnosed with low-risk prostate cancer between 2001 and 2015, with a final follow-up date of March 31, 2020. Of the total cohort, 2280 were African Americans, and the remaining 6446 were non-Hispanic White men.

Though the African American men were more likely to have progression and definitive treatment, they did not appear to be at increased risk of metastasis or death. Rates of metastasis (1.5% vs 1.4%), prostate cancer-specific mortality (1.1% vs 1.0%) and all-cause mortality (22.4% vs 23.5%) were similar among African Americans and non-Hispanic whites, respectively.

Rose and colleagues noted that while many studies over the years have supported the idea of active surveillance in low-risk prostate cancer, those studies have tended to include only a small number of African Americans. This new data, believed to be the largest sample of African American participants in an active surveillance study of men with prostate cancer, suggests that careful active surveillance can be a good option for African Americans. Rose said one factor that matters is whether these patients have access to prompt care.

“It is possible that when carefully observed and promptly treated, the small increased risk of local disease progression may not substantially affect the risk of metastases,” Rose and colleagues wrote.

However, they added that the median follow-up of 7.6 years is still relatively short, and so longer follow-up is necessary to confirm that conclusion.

Still, in an editorial² published along with the study, corresponding author Ronald C. Chen, MD, MPH, and colleagues cautioned that the particular patient population in the study had equal access to care due to their status as veterans entitled to receive care through the VHA. That kind of health equity is not replicated outside of the veterans population, they noted.

“[E]xisting literature has repeatedly demonstrated widespread inequities whereby Black patients with prostate cancer, compared with white patients, are less likely to receive radical prostatectomy and radiotherapy, and are more likely to experience treatment delays,” they wrote.

Chen and colleagues also noted that “active” can have very different meanings when it comes to “active surveillance,” thus some patients may not truly receive the kind of close follow-up care that Rose and colleagues suggest is necessary.

Before physicians and the public health community can be fully confident that African American patients are equally viable candidates for active surveillance, Chen and colleagues wrote, the findings of the new study would need to be replicated in a non-VHA setting.

“Until such evidence is available, concerns about biologic differences in prostate cancer between Black and white men and potential disparities in receiving timely surveillance monitoring and treatment on cancer progression may continue to drive lower rates of active surveillance use among Black patients,” they said.

References

1. Deka R, Courtney PT, Parsons JK, et al. Association between African American race and clinical outcomes in men treated for low-risk prostate cancer with active surveillance. JAMA. 2020;324(17):1747–1754. doi:10.1001/jama.2020.17020
2. Shen X, Pettaway CA, Chen RC. Active surveillance for Black men with low-risk prostate cancer. JAMA.2020;324(17):1733–1734. doi:10.1001/jama.2020.16315