Aggressive Cancer May be Missed: For African American Men, Active Surveillance May Be Risky

If you are an African American man, you should take prostate cancer very seriously because, unfortunately, your life may depend on it. No other group of men in the world shares your risk for getting prostate cancer, of getting the kind that needs to be treated, of having it diagnosed at a later stage, and of dying from it. Now, important research by Brady investigators has shown that even the "best" kind of prostate cancer -- the kind that seems to be very low-risk, the kind that could be treated with active surveillance -- may not be as benign in African American men.

 

Edward Schaeffer, MD, PhD

Urologist, Edward Schaeffer, MD, PhD, was always curious about a striking paradox in prostate cancer… Active surveillance is a highly successful management strategy for men with very low risk prostate cancer yet African American men are more likely to be diagnosed with and die from prostate cancer. Thus was conservative management of African American men a wise choice?


To find out, Drs. Schaeffer, H. Ballentine Carter, MD, Debasish Sundi, MD, Ashley E. Ross, MD, PhD, and their research team, studied 1,801 men who met the National Comprehensive Cancer Network's criteria for very low-risk prostate cancer and were candidates for Active surveillance but elected to undergo immediate prostatectomy instead. The groups consisted of 256 African American men, 1,473 white men, and 72 men of other race. The team investigated pathologic and cancer specific outcomes between the three racial groups. The results were striking: "Surprisingly," says Schaeffer, "African American men had threefold higher rates of more advanced, aggressive disease, which resulted in much poorer outcomes, compared to white men." In other words, their cancer turned out to be more aggressive and more extensive than the initial biopsy and physical exam had suggested.

 
This publication, in the Journal of Clinical Oncology, prompted Schaeffer to team up with renowned prostate pathologist Jonathan Epstein, MD, to study these prostate cancers in more detail. Epstein scrutinized prostatectomy specimens from these men and found that, compared to Caucasian men, the tumors in African American men were larger, of higher grade, and more likely to appear in areas of the prostate that was distinctive from white men (W) in the study. This work was published simultaneously in the Journal of Urology and demonstrated that African American (AA) men had high-grade cancers on the top of the prostate, anterior to the urethra, 59 percent of the time. (see figure) 

Debasish Sundi, MD

"This is an area of the prostate that is particularly difficult to sample with standard biopsy approaches and may be why the more aggressive cancers were "missed" more often in Black men" says lead author on the studies, Dr Sundi. "Unique biopsy protocols or prostate imaging with MRI may help identify these more aggressive anterior tumors," Schaeffer adds, "It also suggests that there may be biologic differences in the prostates of African American men that drive these tumors to develop in a different location and will be a key area of our research in the future"

 
"Although Guideline panels encourage active surveillance as the preferred option for men with very low-risk prostate cancer," explains Schaeffer, "The favorable outcomes achieved for men in active surveillance are based on studies that under-represent African American men." In fact, barely a tenth of the men in most active surveillance programs are black, yet the results are generalized as applying to all men equally Because "very low-risk" cancers in African American men seem different from those in other men, Schaeffer believes that "we need race-specific recommendations" for the treatment of very-low risk cancer. "African American men need to understand these risks when they choose treatment for their prostate cancer. Specifically, they need to know that if they decide on active surveillance, aggressive cancer may be missed."

To read the manuscripts discussed in this blog, follow the links above or the references below.

Sundi D, Ross AE, Humphreys EB, Han M, Partin AW, Carter HB, Schaeffer EM. African American men with very low-risk prostate cancer exhibit adverse oncologic outcomes after radical prostatectomy: should active surveillance still be an option for them?  J Clin Oncol. 2013 Aug 20;31(24):2991-7. doi: 10.1200/JCO.2012.47.0302. Epub 2013 Jun 17.

Sundi D, Kryvenko ON, Carter HB, Ross AE, Epstein JI, Schaeffer EM.  Pathological examination of radical prostatectomy specimens in men with very low risk disease at biopsy reveals distinct zonal distribution of cancer in black American men.  J Urol. 2014 Jan;191(1):60-7. doi: 10.1016/j.juro.2013.06.021. Epub 2013 Jun 14.

To read more about this topic:

From Brady Urological Institute Discovery, Winter, 2014:
http://urology.jhu.edu/newsletter/2014/prostate_cancer_2014_3.php

From the ASCO (American Society of Clinical Oncology) Post, September, 2013:
http://www.ascopost.com/issues/september-1,-2013/active-surveillance-of-very-low-risk-prostate-cancer-might-not-be-suitable-option-for-african-american-men.aspx