Race and Mortality in Prostate Cancer

Educational Objectives

The goal of this program is to improve patient outcomes by eliminating health care inequities in prostate cancer. After hearing and assimilating this program, the clinician will be better able to:

1. Explain outcomes in prostate cancer in Black vs White men as shown in the Surveillance, Epidemiology and End Results database.
2. Cite evidence about progression of prostate cancer associated with race, obesity and socioeconomic status.

Summary

Introduction: disparities in the outcomes of prostate cancer (CaP) in men who self-identify as Black have been evident since 1970s, when outcomes were first presented in the Surveillance, Epidemiology and End Results (SEER) database; according to data, Black men are almost twice as likely to die of prostate cancer than White men; possible causes include inherited genetic factors, environmental factors, toxins, diet, nutritional issues, care dynamics, and care quality and availability; age-adjusted SEER data for 2014 to 2018 shows observed ratio of 1.7 (Black to White men) in new cases per 100,000 persons; death rates were 17.9 White men and 37.4 Black men per 100,000 persons; there was increased incidence of CaP associated with prostate-specific antigen (PSA) screening around the early 1990s; most recent SEER data show relative rate of mortality rates for Black vs White men is ≈2.0

Mechanisms: biologic difference between Black men and White men has been proposed; Black men may be more susceptible to prostate cancer; however, the genetic variation of Black men and White men is very high; the concept of genomic ancestry is a possibility (eg, inherited genes from West African ancestry, Black men that trace their lineage could be at higher risk); disease-causative genetic variations might lead to somatic changes in disease outcomes; other potential factors include risk factors, exposures, behaviors, and access, delivery, and receipt of adequate health care

Evidence on race and chronic prostate cancer: according to Dess et al (2019), self-identified Black men have a higher PSA and higher grade disease at diagnosis when controlled by age; also appear to have a higher progression and treatment rate on active surveillance; obese men have higher recurrence rates after surgery regardless of race; obesity and race are risk factors; lower socioeconomic status is associated with higher all-cause mortality for Black and White men; no difference in skeletal related events or overall mortality by race for men with bone metastatic prostate cancer in an equal access health care environment; the time to metastases did not differ for men treated with androgen deprivation therapy (ADT) for biochemical recurrence after radical prostatectomy

Race as a social construct: the ethnic backgrounds and inheritance patterns of self-identified Black Americans is very diverse; the era of slavery vs modern immigration yields very different inheritance patterns; the region of African ancestry in generations and region in the US are potential influencers; there is very high variability and a high admixture of European ancestry, 30% to ≥50%; Dess et al (2019) studied the association of Black race with prostate cancer-specific and other cause mortality in 3 cohort groups; data included SEER data base group (uncontrolled), Department of Veterans Affairs group (equal access health care), and Radiation Therapy Oncology Group (RTOG; randomized clinical trials) from 1992 to 2013; assessing competing risks for prostate cancer-specific mortality, Black men appeared at higher risk in the SEER database, but in the VA cohort, and in the RTOG group, Black men were not at higher risk for prostate cancer-specific mortality; suggests access and delivery of excellent care seems to dampen the apparent increased risk of self-identified Black men; speaker estimates 4000 men dying from prostate cancer a year in America can be saved if their mortality is similar to White Americans

Readings

Dess RT, Hartman HE, Mahal BA, et al. Association of black race with prostate cancer–specific and other-cause mortality. JAMA Oncol. 2019; 5(7):975–983. doi:10.1001/jamaoncol.2019.0826; DeWitt-Foy ME, Gam K, Modlin C, et al. Race, decisional regret and prostate cancer beliefs: Identifying targets to reduce racial disparities in prostate cancer. J Urol. 2021; 205(2):426-433. doi:10.1097/JU.000000000000138; Nettey OS, Walker AJ, Keeter MK, et al. Self-reported Black race predicts significant prostate cancer independent of clinical setting and clinical and socioeconomic risk factors. Urol Oncol. 2018; 36(11):501.e1-501.e8. doi:10.1016/j.urolonc.2018.06.011; Vidal AC, Oyekunle T, Howard LE, et al. Obesity, race, and long-term prostate cancer outcomes. Cancer. 126 (2020),3733-41, 10.1002/cncr.32906.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Kane is a stock owner at Stratify Genomics. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Kane was recorded at the 29th Annual Perspectives in Urology: Point Counterpoint, held November 18-21, 2021, in Coronado, CA, and presented by Grand Rounds in Urology. For information about upcoming CME activities from this presenter, please visit Grandroundsinurology.com. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.25 CE contact hours.

Lecture ID:

UR451401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.