At the time of this writing, the long-time co-host and weatherman of the Today show, Al Roker, is recovering from prostate cancer (PCa) surgery. Roker used his air time to announce his diagnosis of early stage but aggressive disease, in part as a chance to raise awareness of PCa among black men. “The problem for African American men is any number of reasons from genetics to access to healthcare, and so we want to make it available and let people know they got to get checked,” he cautioned.^[i]

Roker’s summary reflects the ongoing dialogue—and at times, debate—in the clinical world over prostate cancer (PCa) among African American men. Are black men at greater risk, and if so, why? As Roker put it, because of “any number of reasons.” Let’s look at that more closely.

Here are the facts. African Americans comprise 13.4% of the U.S. population, but black men have roughly twice the PCa-specific mortality rates as white men. While it’s true that cancer death rates in general are coming down, when it comes to PCa the distribution is hardly equal. Historically, from 1999–2017, non-Hispanic black males had the highest prostate cancer death rate. In 2017, the rate for non-Hispanic black males was 36.8%, compared with 17.8% for non-Hispanic white males and 15.4% for Hispanic males.^[ii] These are recent numbers, but they don’t explain the underlying causes.

Different gene pools?

Traditional theories about so-called racial differences led to widespread beliefs that inherent traits made African descendants in the U.S. more likely to develop PCa. Such a fatalistic view led to biased “scientific” studies that had a racist, self-fulfilling prophecy quality. In other words, if you want to prove what you believe, you’re more likely to look for evidence that supports it. This is not true science.

In fact, the largest study to date of higher mortality rates among black PCa patients brings new information to light. The 2019 study, “Association of Black Race with Prostate Cancer-Specific and Other-Cause Mortality,” involved multiple, well-respected institutions analyzing an impressive 306,100 prostate cancer cases.^[iii] With the objective of calculating PCa-specific mortality, and secondarily other-cause mortality (OCM), statistical adjustments were made for “demographic-, cancer-, and treatment-related baseline differences” in order to control for prognostic variables and access to care.

Co-author Daniel Spratt MD (Genitourinary Clinical Research at the University of Michigan (U-M) says,

The data show that black men don’t appear to intrinsically and biologically harbor more aggressive disease… They generally get fewer PSA screenings, are more likely to be diagnosed with later stage cancer, are less likely to have health insurance, have less access to high-quality care and other disparities that can be linked to a lower overall socioeconomic status.^[iv]

In the words of the paper itself, “With similar access to care and standardized treatment, black men with nonmetastatic prostate cancer appeared to have comparable stage-for-stage prostate cancer–specific mortality to white men.” At the same time, the paper notes that black men “… are also more likely to have comorbid illness such as cardiovascular disease and diabetes, diagnoses that are negatively associated with survival outcomes with or without prostate cancer.” This suggests that better healthcare access would benefit black PCa patients (and, I might add, many more underprivileged groups).

Gene mutations

The above study, however, does not rule variances in gene mutations, though the origins of population subgroup mutations may be lost in the slow process of evolution. For example, the mutations that cause a rare inherited disease called Tay-Sachs are more prevalent among people of Ashkenazi Jewish heritage, but how this came to be is still a matter of hypothesis.

Such is the case with apparent distinctions that are still ascribed to “race” but, as genetic evidence increasingly disputes this, we have yet to replace the term “race” with something better. In any case, a 2019 study published in Molecular Cancer Research is titled “Distinct Genomic Alterations in Prostate Tumors Derived from African American Men.” Biological and genomic analysis of prostate tumors from 77 African American PCa patients revealed that over 35% the tumors had evidence of potentially damaging mutations in several genes. One specific mutation was identified in 11.7% of the black patients vs. 2.7% of white patients found to have the same mutation. In addition, when pooling several public databases that include both black and white patients, the researchers found that, in high-grade tumors but not low-grade disease, black patients were more likely to have certain gene mutations than white patients. (The authors acknowledge that more research is needed to verify their results.)

There is contrasting genomic news from a collaborative research team from UCSD and Harvard Medical School. Using data from the Veterans Administration, an equal-access healthcare system, the team analyzed data on clinical outcomes for low-risk PCa patients managed with active surveillance (AS) from 2001-2015. There were two cohorts: 2280 black veterans and 6446 white veterans. AS was loosely defined as “no definitive treatment within the first year of diagnosis and at least 1 additional surveillance biopsy.”^[v] Both cohorts 12 PSA tests and 2 biopsies with no difference in time to second biopsy. While the team confirmed differences apparent in most demographic studies (i.e. for black men, younger age at diagnosis, higher incidence of progression at 10 years follow-up), AS was as safe for black as white men. Specifically, rates of metastasis, PCa-specific mortality, and other-cause mortality were basically equal.

This blog is hardly a comprehensive presentation of the ongoing search for an understanding of the statistical divergences between black and white PCa incidence and clinical outcomes, but I hope I have represented the process of examining biological and access-to-care considerations, and the relationship between them. I have an even greater hope that as science untangles the sources of such distinctions through the lens of prostate cancer, it will be another contribution toward resolving the problem of “racial divisions.” While there is much genetic variation among population subgroups by skin color and geography, A National Geographic article title says it succinctly: “There’s No Scientific Basis for Race—It’s a Made-up Label.”^[vi] The fact is, PCa is simply blind to color.
 
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

[i] Michele Berman & Mark Boguski. “Al Roker’s Prostate Cancer.” MedPage Today, Nov. 10, 2020. https://www.medpagetoday.com/blogs/celebritydiagnosis/89586
[ii] https://www.cdc.gov/mmwr/volumes/68/wr/mm6823a4.htm
[iii] Dess RT, Hartman HE, Mahal BA, Soni PD et al. Association of Black Race With Prostate Cancer-Specific and Other-Cause Mortality. JAMA Oncol. 2019 Jul 1;5(7):975-983.
[iv] https://labblog.uofmhealth.org/lab-report/study-explores-why-prostate-cancer-mortality-higher-black-men
[v] Deka R, Courtney PT, Parsons JK, Nelson TJ et al. Association Between African American Race and Clinical Outcomes in Men Treated for Low-Risk Prostate Cancer with Active Surveillance. JAMA. 2020 Nov 3;324(17):1747-1754. doi: 10.1001/jama.2020.17020.
[vi] Elizabeth Kolbert. “There’s No Scientific Basis for Race – It’s a Made-up Label.” National Geographic online. Mar. 12, 2018.