Implications for Reducing Prostate Cancer Disparities



The elimination of racial and ethnic disparities in health is an overarching goal of U.S. public health policy. Although the magnitude of the disparities is evidenced in a plethora of diseases across racial and ethnic groups, the extent of the problem is no more clearly illustrated than in cancer among African Americans. Overall, they are more likely to develop and die from cancer than any other racial and ethnic group. Healthy People 201(P reports that “African Americans are about 34% more likely to die of cancer than are whites and more than two times more likely to die of cancer than are Asians or Pacific Islanders, American Indians, and Hispanics.” In further defining the unequal burden of cancer, no other cancer provides a more compelling case for eliminating disparities in African-American men.


Epidemiological Data

Prostate cancer is the most common cancer (excluding skin cancer) and the second leading cause of cancer death among U.S. men. An estimated 230,110 new cases will be diagnosed, and 29,900 deaths will occur in 2004. Despite overall declines in U.S. prostate cancer incidence and mortality rates, both rates remain significantly higher in African-American men, compared to Caucasian men. African-American men are more than twice as likely to die of prostate cancer than men of any other racial and ethnic group. In fact, African-American men continue to experience the highest prostate cancer incidence and mortality rates in the world. canadian pharmacy support net

In addition, previous research has reported disproportionately lower survival rates and higher mortality rates for cancer, including prostate cancer, among the socioeconomically disadvantaged and medically underserved, compared to persons at higher income levels. In discussing cancer disparities, a recent report indicated that “poor and medically underserved populations have higher risks of devel­oping cancer and poorer chances of early diagnosis, optimal treatment, and survival.” For instance, the gap in prostate cancer deaths between poor and wealthy men has continued to widen since 1990, resulting in a 22% higher prostate cancer death rate in 1999 for men in poorer counties compared with men in affluent counties, according to data from the Surveillance, Epidemiology, and End Results (SEER) program. In spite of decades to alter these trends, such disparities remain significant and unresolved public and community health problems.

Risk Factors

The possible explanations for the alarming disparity in prostate cancer outcomes are multifactorial and imply a synergistic relationship between biologic, socioeconomic, lifestyle, cultural, environmental and/or occupational factors. According to the American Cancer Society, the only well-established risk factors for prostate cancer are age, ethnicity, and family history in that: a) >70% of cases are diagnosed in men over 65 years old, b) African-American men hold commanding leads in both incidence and mortality, and c) recent genetic studies suggest a strong familial predisposition being responsible for 5-10% of prostate cancers. Recent international studies also suggest dietary fat as a risk factor. Since the definitive biologic etiology of prostate cancer remains unknown, further investigation is warranted to substantiate the influence of modifiable, nonbiologic risk factors on prostate cancer disparities.

Previous research has reported disproportionately higher risks of developing cancer, lower survival rates and higher mortality among the socioeconomically disadvantaged and medically underserved in comparison to persons at higher income levels. In emphasizing the association of socioeconomic status (SES) to cancer risk, poverty has been described as a carcinogen. This is particularly relevant for African Americans. Although African Americans comprise approximately 12% of the total U.S. population, they account for one-third of the nation’s poor. Thus, the cancer risk for poor African Americans is profound.

Inasmuch as African-American men are more likely to be diagnosed in later stages of prostate cancer than their European-American counterparts, it is likely that aspects of SES, such as access to care and education, play a major role. For example, low economic status may be associated with limited access to care, not having health insurance, and later detection. In turn, late detection may result in a lower cure rate, shorter survival, and higher mortality.

Lack of prostate health knowledge is also a major factor contributing to the African-American male population’s failure to participate in screening, presentation with more advanced disease, lower cure rate and shorter survival. These men know very little or nothing about prostate health, prostate cancer, its symptoms, its well-described risk factors (age, African-American race, family history, high fat diet) or the importance of cancer prevention, early detection and screening. More often than not, what little they do know is shrouded in misinformation, misunderstanding and myths, leading to a severe knowledge gap that leaves them chronically uninformed.
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This knowledge gap directly impacts their prostate health and prostate cancer behavior. Ironically, even if chemopreventive measures for prostate cancer became mainstream, the benefit to socioeconomically disadvantaged, medically underserved, African-American men would be minimal, due in large part, to lack of credible information. Hence, the portrait of African-American men reflects a highly vulnerable population still at risk for prostate cancer’s most profound adverse effects.

Thus, the impact of factors associated with low SES in combination with higher prostate cancer incidence and mortality based on race present a compelling healthcare challenge. These factors place socioeconomically disadvantaged, medically underserved, African-American men in double jeopardy for adverse prostate cancer outcomes.

Detection and Treatment of Prostate Cancer

Far too often, being asymptomatic implies wellness, a particularly dangerous assumption in many disease processes, including prostate cancer. Thus, the two commonly used early detection methods for prostate cancer, i.e., the digital rectal exam (DRE) and the prostate-specific antigen (PSA) test, are underutilized relative to the recommendations. Granted, extensive debate surrounds whether or not widespread screening reduces deaths or if early treatment is more effective than treatment of late or advanced prostate cancer in prolonging life. Friedrich points out that it is unclear whether screening is associated with decline in mortality. Similarly, Hahn proposes that we “cannot know whether PSA decreases” cancer morbidity and mortality, since the results of randomized controlled trials for prostate cancer screening and detection are not available. This issue is compounded by the fact that actual sensitivity, specificity and predictive value of the DRE and the PSA are low.

However, in spite of the controversy, men should have accurate information about the benefits and limitations of screening to enable them to make informed decisions regarding participation in testing. The American Urological Association (AUA) and the American Cancer Society (ACS) recommend that prostate cancer screening begin by age 50 for men without relevant risk factors (i.e., race/ethnicity, a strong family history of prostate cancer, etc.). In the case of African-American men who are at high risk for prostate cancer and its associated morbidity and mortality outcomes, ACS and AUA recommend that an early detection program begin five-to-10 years earlier (i.e., 45 years of age and 40 years of age, respectively). buy cialis soft tabs

Further concerns focus on the patient’s lack of or limited understanding of the implications of a positive test result and the physician’s inability to effectively educate and/or counsel the patient about the test results. O’Dell and colleagues concluded from a study that focused on informed decision-making among 160 men aged 45-70 that less-educated men might not avail themselves of screening because of lack of prostate cancer knowledge. The issues surrounding screening, detection, and treatment are further compounded when one considers the limited information or misinformation that some physicians convey to the patient.

In spite of these screening-related drawbacks, there is no known means of preventing prostate cancer currently available or on the horizon. The only “practical strategy for reducing cancer suffering and death” is appropriate early detection. However, given the target population’s absent to limited knowledge about prostate health or prostate cancer, they are not likely to avail themselves of early detection opportunities. Therefore, the purpose of this exploratory pilot study was: a) to assess the knowledge of a cohort of low-SES, African-American men regarding prostate health, prostate cancer, screening, diagnosis, and treatment and b) to uncover myths, misinformation, and misunderstanding that serve as barriers to their prostate health decisions and behaviors. eriacta 100 mg