Originally published 2/26/2015
Over eight years ago, we posted a recommended caution that men of African American descent discuss possible risks of going on Active Surveillance (AS) even when early clinical factors suggested they qualify for AS. Then, the authors of a 2018 paper noted that the observational studies encouraging more use of AS were largely composed of White men, raising the question of whether positive results of those studies should be applied to Black men. After reviewing studies that focused on Black men, they concluded, “The preponderance of evidence demonstrates that AS is as viable a management method for [African American man] with low-risk prostate cancer as it is with other racial groups.”[i] More recently, two studies were published in 2021:
- A team from The Lewis Katz School of Medicine at Temple University found that at this own center, Black men had a higher rate of converting to definitive treatment based on PCa progression than their White counterparts, pointing to a need for strict observance of monitoring protocols and repeat biopsy.[ii]
- A study of 773 Veterans Administration patients with low-risk intermediate PCa compared Black and White men on Active Surveillance. The researchers, from UC San Diego, found that outcomes were similar for both groups, and that “…African American race was not associated with increased risks of definitive treatment, disease progression, metastasis, PCSM, or all-cause mortality.”[iii] In short, this study suggests there is equal safety regardless of ethnicity/race.
Since research results differ, it is not yet possible to generalize regarding the safety of AS for African American men. Therefore, we stand by our original position that a) Black men for whom AS appears to be an option should discuss the mixed research findings with their doctors, and b) results of a multiparametric MRI should be obtained before making a treatment decision in order to add what may be key information for or against AS. No matter what, all men on AS should strictly comply with their doctors’ instructions for monitoring.
African American men had a higher incidence of prostate cancer (PCa) than Caucasian men. They are 2.5 times as likely to die from prostate cancer than Caucasians. There are numerous theories about why this occurs, including genetic differences, lifestyle and nutrition, and differences in medical care or access to medical care. Experts lean toward a combination of these and other factors.
In the past 2-3 years, much more attention has been placed on offering Active Surveillance (AS) to men diagnosed with very low risk disease. A Johns Hopkins research team analyzed the follow-up prostate biopsies used to monitor AS patients for disease progression to compare rates of PCa upgrading between Caucasian and African American patients.[i]
All of the patients who began AS were diagnosed with very low risk disease, determined by the criteria of the National Comprehensive Cancer Network:
- Clinical stage < T1
- Gleason score < 6
- PSA < 10 ng/mL*
- PSA density < 0.15 ng/ML/cm3
- Less than 3 positive biopsy cores
- Cancer per core < 50%.
The results showed that African American men on AS were more likely to be reclassified to a higher grade based on biopsy results (36% vs. 16%). Even when other factors such as PSA, gland size, etc. were taken into account, race was an independent predictor, and was independently associated with reclassification by Gleason score though not by tumor volume. The authors concluded that the risk of upgrading was significantly higher for African American men. They suggest that different selection criteria might be required for African American men considering AS as a disease management strategy.
Until observed racial, ethnic and demographic differences in prostate cancer occurrence and outcomes are better understood, I encourage African American men newly diagnosed with prostate cancer to discuss this study with their doctors. In addition, getting a baseline 3T mpMRI of the prostate enables image-based monitoring of their disease as a way to know when a repeat biopsy is warranted.
For more information on AS, see the following links:
https://sperlingprostatecenter.com/mri-active-surveillance/
https://sperlingprostatecenter.com/monitoring-small-lesions-using-mri-interval-safe-surveillance/
https://sperlingprostatecenter.com/imaging-helps-predict-candidates-active-surveillance/
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.
References
[i] Leinwand GZ, Gabrielson AT, Krane LS, Silberstein JL. Rethinking active surveillance for prostate cancer in African American men. Transl Androl Urol. 2018 Sep;7(Suppl 4):S397-S410.
[ii] Kidd LC, Loecher M, Ahmed N, Terzian J, Song J, Reese AC. Prostate cancer active surveillance outcomes in a cohort composed primarily of African American and Hispanic American Men. Urol Oncol. 2021 Oct;39(10):730.e1- 730.e8.
[iii] Courtney PT, Deka R, Kotha NV, Cherry DR et al. Active surveillance for intermediate-risk prostate cancer in African American and non-Hispanic White men. Cancer. 2021 Dec 1;127(23):4403-4412.
[iv] Sundi D, Faisal FA, Trock BJ et al. Reclassification rates are higher among African American men than Caucasians on active surveillance. Urology. 2015 Jan;85(1):155-60.
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
