When my friend Dan was diagnosed with prostate cancer, he did something radical. Based on Dan’s biopsy and other test results, his cancer was deemed to be very low risk. Many men in that situation are advised to skip surgery or radiation because their cancers probably will progress so slowly that the risks of treatment outweigh the benefits. Yet Dan’s doctor told him that he should have his prostate surgically removed—and that’s what Dan opted to do.
Normally I’d be angry if a surgeon pushed a friend to have an operation that seemed unnecessary. But in this case, Dan’s doctor probably made the right call, because he took into account a risk factor that’s often ignored—the patient’s race. Because Dan is black, the current treatment guidelines, which were written without regard to race, may not be appropriate for him and others like him, a recent study reveals.
THE COLOR OF RISK
About one in every six men will be diagnosed with prostate cancer at some point in his life, yet only one in 36 men will die of the disease. Because the vast majority of prostate cancers are not fatal—and because treatment with surgery and/or radiation can cause incontinence and erectile dysfunction—many men with very-low-risk cancer are advised to skip treatment in favor of active surveillance (formerly called “watchful waiting”). They go for frequent follow-up exams…and treatment is recommended only if the cancer shows signs of progressing over time.
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The researchers reviewed the records of 1,801 men who were considered to have very-low-risk prostate cancer based on criteria from the National Comprehensive Cancer Network. These include a low PSA (a prostate-specific antigen score of less than 10)…low-grade cancer (a Gleason score of six or less)…low-volume cancer (fewer than three cores involved)…and low PSA density of less than 0.15. (Patients can check with their doctors to see whether their cancer meets these criteria.)
Of the 1,801 men in the study, 1,473 were white…256 were black…and 72 were of other races. Though these men had all been candidates for active surveillance, they had all opted instead for surgical removal of the prostate gland. This gave the researchers access to pathology reports on cancer staging and other information that could not have been determined from small biopsy samples. The researchers analyzed this information to see whether there were any differences in cancer characteristics among men of various races.
WORRISOME RESULTS
Based on what could be determined prior to surgery, all of the men’s cancers seemed to be similarly low-risk regardless of race. However, based on detailed postoperative examinations, Dr. Schaeffer’s research team found that the African-American men had far more serious cancers. For instance, the black men in this study were more likely to have…
- Adverse pathological findings (larger, more aggressive cancers)—14% for blacks versus 8% for whites and 7% for other races.
- Cancers that had already spread beyond the prostate gland—12% for blacks versus 9% for whites and 8% for other races.
- Gleason scores that needed to be “upgraded” (raised to a more aggressive grade)—27% for blacks versus 14% for whites and 24% for other races.
- Positive surgical margins (meaning that the surgery did not get rid of all the cancer cells)—10% for blacks versus 6% for whites and 4% for other races.
- Biochemical recurrence (the return of detectable levels of PSA in the blood)—4% for blacks versus 1% for whites and other races.
- A higher estimated risk for recurrence in the five years following treatment (a calculation called the CAPRA-S)—15% for blacks versus 7% for whites and 8% for other races.
Latest data: The Hopkins researchers also looked at the subset of men treated using modern treatment standards, after the practice of taking more biopsy samples was established. In this subset, black men continued to be at higher risk based on upgraded Gleason scores, cancer cells remaining and risk for recurrence—in fact, there were even worse gaps between black patients and patients of other races than there had been in the first stage of the study!
During a subsequent follow-up period, which averaged about three years, there were no differences in death rates based on race. However, three years is not a very long follow-up time for a typically slow-moving cancer. Dr. Schaeffer noted that he would not expect to see differences in death rates until at least 10 to 15 years after the men were treated.
WHAT THIS MEANS FOR MEN
This study’s findings have nothing to do with racial disparities in access to health care, because all the men were deemed to be at similar risk based on presurgical tests and all had the same treatment. So why did the black patients fare worse? The short answer is, medical science doesn't know. Dr Schaeffer’s team is actively perusing research leads to discover what may cause black men to harbor more dangerous, more aggressive and/or more developed prostate cancers than white men even when the currently used diagnostic tests come up with similar findings.
Whatever the cause, though, this is a dangerous situation for black men.
This study does not mean that active surveillance is entirely wrong for all black men. But it does emphasize the fact that treatment guidelines are not equally appropriate for everyone, especially when those guidelines are based on studies that did not include adequate racial diversity. Clearly, more research is needed to figure out how race-specific criteria should be factored into diagnoses and into the determination of optimal treatment.
Bottom line: Until this additional research is done, it’s important for patients to talk with their doctors about how their race impacts their prostate cancer treatment options. For instance, Dr. Schaeffer recommended that all men who are considering active surveillance also think about getting an MRI of the prostate—but an MRI is especially important for black men because they tend to have larger tumors located in areas of the prostate that are not as easily accessible for biopsy.
Source: Edward M. Schaeffer, MD, PhD, physician and associate professor of urology, oncology and pathology, Johns Hopkins University School of Medicine and Johns Hopkins Hospital, Baltimore. His study was published in Journal of Clinical Oncology.
http://www.bottomlinepublications.com/content/article/health-a-healing/should-you-treat-your-prostate-according-to-your-race
