Prostate Cancer: What African-American Men Need to Know
A recent report from the UW Cancer Health Disparities Initiative (CHDI) had the shocking news that African-American men in Wisconsin are 71 percent more likely to be diagnosed with prostate cancer and die of it more often than white men.
Dr. Tracy Downs, UW Health cancer surgeon and current president of the national association of black urologists, the R. Frank Jones Urological Society, offers his perspective on these numbers. Downs is faculty director of CHDI, which has community partnerships and a research project aimed at improving the health of black men in Wisconsin.
What do you think is behind these numbers?
I’ve been here in Wisconsin eight years, and as an outsider coming in, you hear great things about Dane County: well-educated people and a high percentage of them with good insurance. But then, the “Race to Equity” report looked under the proverbial rock and said, “Maybe that narrative is not the same for everyone in Dane County.” CHDI’s recent report says the cancer narrative is also different for African Americans in Dane County and Wisconsin.
We know that social determinants of health -- where you live, your education level, your unemployment rate -- all those “bad actors” on public health were lopsided against the health of African Americans. So, if you have the headline: State cancer rates getting better, you have to add the subhead, But not as quickly for African-American men.
Is there a reason the prostate cancer rates are especially bad?
Lung cancer rates are also worse, but prostate uniquely jumps off the page. In general, prostate cancer news (on whether PSA tests are a good idea) has people confused. About five years ago, the U.S. Preventive Task Force message saying not to get screened got broadcast to all groups. Unfortunately, African-American men, the group most at risk, are also most likely not to get screened at all, to be diagnosed at a later stage, and to die.
They should have heard a different message that wasn’t communicated. When the USPT recommendation came out, over-diagnosing and over-treatment were the buzzwords. What happened is we saw a decrease in screening, and also a drop-in diagnosis while the mortality rate was increasing.
But this is a group that is not doing as well as other Americans to begin with on prostate cancer, so let’s follow through with screening. We can figure out later whether it’s a cancer that needs treating. It’s the over-treating that is the problem, not the over detection. We’re smart enough now to know which group needs treatment.
Why is this such a tragedy for the community?
Here is a community that loses young men to criminalization and prison, and then on the other side of the lifespan, we’re losing more wise, experienced elders of our community to cancer. The role of the African-American male in his own community is getting smaller in many ways. Too many younger men are not out in the general population, and then the older men who have survived all the hoops are dying a decade younger due to many causes -- cancer, heart disease, diabetes.
Can community members make a difference?
When I first started (as a physician) in the 1990s, men were very fearful of the rectal exam, and reasons why the exam was important, were communicated by a health-care provider. If the message would have come from someone they trust, someone who lives in their community, giving advice on the benefits of the exam, they would have more likely heard it and acted on it.
Trying to help men advocate for themselves in the doctor’s office is part of our initiative with 100 Black Men of Madison. The way you change that equation is maybe not the way I’ve been taught as a physician, but to maybe level the field on the patient side.
It’s hard to think of a community group being everything to everyone. With prostate cancer, we’re always limited by insurance. What about things like ads, incentives, what about health insurance companies incentivizing healthy behavior such as getting your screening? We also need health navigators for men to help guide them through the system.
How could the health care system be improved?
In early localized prostate cancer, the treatments offered to African-American men are less likely to be curative treatments. They tend to be offered hormone-lowering drugs more than white men, and they also tend to be offered radiation therapy rather than surgery. When they should have a lymph node dissection, they’re less likely to be offered that. So, there could be some biases there.
It could also be a question of where they are getting their care. Are they in academic medical centers, or in places where the teams are less experienced in those treatments?
You also ask, is it a “one and done” consultation, or building a relationship with the patient? Who would say yes to some of these options the first time they heard about them? Maybe the physician should say, “I fully understand where you’re coming from, but let’s see you back in a few weeks and talk some more.” Then offer some videos or readings so they can build their knowledge in the meantime.
With advanced cancer, where it is no longer responding to hormonal treatment, or has advanced to the bones, we have made great progress with new drugs that improve survival. Unfortunately, the percentage of African American men in those trials is small and their chances of getting the drugs rather than placebo in the trials are also small. One of the new drugs, an immunotherapy vaccine, has shown promise of actually being more effective in African-American men. Some of the leaders in our African-American Urology association are working to get the drug to more men.
So, is there a biological difference? We don’t know that. But we do know there are differences in lower screening levels; in therapeutic options offered at treatment; in the levels of treatment provided; and in more advanced cancer, there are very few African-American men in the novel clinical trials that have been well done. So, we have lots we can work on to reduce the prostate cancer burden for African American men.
The full report, Trends in Cancer Disparities between African-Americans and Whites in Wisconsin, focuses on prostate, breast, lung and colon cancers and the higher burden faced by African-Americans.
Date Published: 09/12/2018