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Prostate cancer health disparities: African American men: high morbidity and mortality.

According to the National Cancer Institute (NCI), African- American men (AAM) have the highest incidence of prostate cancer among ethnic groups in the United States. This is a major health disparity. Health disparities systematically affect groups of people who have experienced greater obstacles to health based on factors such as race, ethnicity, gender, sexual orientation, geographic location, education, socioeconomic status, age, lack of health care coverage and mental or physical disabilities.

The incidence of prostate cancer and subsequent prostate cancer deaths among African Americans are double that of other ethnic groups. What are the contributing factors for this disparity? Studies have looked at the cause for these higher rates of morbidity and mortality and found that biologic and socioeconomic factors play a significant role. One study of US Service men showed African American men still had a higher rate of prostate cancer regardless of socioeconomic status or access to care. (2) But, the Institute of Medicine 2002 report, "Unequal treatment: Conforming Racial and Ethnic Disparities in Health Care" found there was evidence that racial minorities received lower-quality healthcare than whites even when factors such as access to care, insurance and income were controlled. (3) It has also been suggested that the high incidence of prostates cancer among African American may be a function of genetic predisposition. Epidemiologic studies looking at men of African descent from Nigeria and Ghana found they had similarly high incidences of prostate cancer when compared to men of African descent in Caribbean islands and in the United Kingdom. (4) Studies have also shown that in African American men there are higher rates of chromosomal variants. Gene EphB2 impairs tumor suppression and gene BCL2 causes premature cell death. These genetic differences may explain the higher incidences of prostate cancer morbidity and mortality rates among AAM. (5) At the time of diagnosis, AAM also tend to have more aggressive disease which may contribute to higher rates of mortality. (6) Additionally, advanced or metastatic disease was nearly four times more frequent in AAM. (7) Curative therapies including radiation or radical surgery may also be recommended less often due to co-morbidities and socioeconomic considerations. (8-11)

It has been suggested that diet and lifestyle may be contributing factors to prostate carcinogenesis. This includes diet high in dairy proteins and calcium intake greater than 200mg per day. (12-13) Obesity is also shown to increase to risk of more aggressive cancer and is associated with shorter bio-chemical relapse free survival in AAM. (14-15) Physical activity of 30 minutes per day and not smoking was associated with a lower risk for prostate cancer. (16-17)

The Prostatic-specific Antigen (PSA) test is the universally known screening test for prostate cancer. There is some debate on whether this test should be performed in asymptomatic men because of associated overdetection or overtreatment of indolent disease. (18) However, despite the debate on when screening should begin, there is consensus that early detection is the best way to lower mortality and ultimately decrease health disparity among African Americans as well as other ethnic groups. Clinicians should discuss the importance of early detection with patients and perform an annual prostate digital rectal exam. They should also provide education on the benefits of treatment and the risks associated with treatment options. An educational Q&A is a great opportunity for patients to ask questions about the disease process and may serve to alleviate many of their fears about disease management. If this is consistently done, then we may start to see improvement in prostate cancer outcomes among AAM.

References:

(1.) Age-adjusted Rates and Trends by Race/Ethnicity. Seer Cancer Statistics Review (http://www.seer.cancer.gov/csr) (2006-2010)

(2.) Wells TS, Bukowinski AT, Smith TC, et al. Racial differences in prostate cancer risk remain among US servicemen with equal access to care. Prostate 2010; 70:727-734.

(3.) Smedley BD. Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Institute of Medicine. National Academy Press; Press 2002

(4.) Odedina FT, Akinremi TO, Chinegwundoch F, et al. Prostate Cancer disparities in black men of African Descent: a comparative literature review of prostate cancer burden among black men in the United States, Caribbean, United Kingdom, and West Africa. Infect Agent Cancer 2009; 4(suppl 1):52

(5.) Robbins, CN, Hooker S, Kittles RA, Carpten JD. Ephb2 SNPs and sporadic prostate cancer risk in African American men. PLos One 2011; 6:e19494.

(6.) Ndubuisi SC, Kofie VY, Andoh JY, Schwartz EM. Black-white differences in the stage at presentation of prostate cancer in the District of Columbia. Urology 1995; 46:71-77

(7.) Powell IJ, Bock CH, Ruterbusch JJ, Sakr W. Evidence supports a faster growth rate and/or earlier transformation to clinically significant prostate cancer in black than in white American men, and influences racial progression and mortality disparity. J Urol 2010; 183:1792-1796.

(8.) Moses KA, Paciorek AT, Penson DF, Carroll PR, Master VA. Impact of ethnicity on primary treatment choice and mortality in men with prostate cancer: data from CaPSURE. J Clin Oncol 2010; 28:1069-1074.

(9.) Demers RY, Tiwari A, Wei J, Weiss LK, Severson RK, Montie J. Trends in the utilization of androgen-deprivation therapy for patients with prostate carcinoma suggest an effect on mortality. Cancer 2001; 92:2309-2317.

(10.) Hsing AW, Chokkalingam AP. Prostate cancer epidemiology. Front Biosci 2006; 11:1388-1413.

(11.) Schwartz K, Powell IJ, Underwood W 3rd, George J, Yee C, Banerjee M. Interplay of race, socioeconomic status, and treatment on survival of patients with prostate cancer. Urology 2009; 74:1296-1302

(12.) Gonzalez CA, Riboli E. Diet and cancer prevention: contributions from the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Eur J Cancer 2010; 46:2555-2562.64.

(13.) Rodriguez C, McCullough ML, Mondul AM, et al. Calcium, dairy products, and risk of prostate cancer in a prospective cohort of United States men. Cancer Epidemiol Biomarkers Prev 2003; 12:597-603.

(14.) Rodriguez C, Freedland SJ, Deka A, et al. Body mass index, weight change, and risk of prostate cancer in the Cancer Prevention Study II Nutrition Cohort. Cancer Epidemiol Biomarkers Prev 2007; 16:63-69.

(15.) Spangler E, Zeigler-Johnson CM, Coomes M, Malkowicz SB, Wein A, Rebbeck TR. Association of obesity with tumor characteristics and treatment failure of prostate cancer in African-American and European American men. J Urol 2007; 178:1939-1944

(16.) Watters JL, Park Y, Hollenbeck A, Schatzkin A, Albanes D. Cigarette smoking and prostate cancer in a prospective US cohort study. Cancer Epidemiol Biomarkers Prev 2009; 18:2427-2435.78.

(17.) Orsini N, Bellocco R, Bottai M, et al. A prospective study of lifetime physical activity and prostate cancer incidence and mortality. Br J Cancer 2009; 101:1932-193

(18.) Duffy MJ. Prostate-specific antigen: does the current evidence support its use in prostate cancer screening? Ann Clin Biochem 2011; 48:310-316

Denise Rowe, MSN, APRN, FNP, BC
Prostate Cancer Incidence and Death Rates (1)

 Prostate Cancer

Racial/Ethnic Group Incidence Death

All races 152.0 23.0
African American/Black 228.5 50.9
Asian/Pacific Islander 81.8 10.1
Hispanic/Latino 125.8 19.2
American Indian/Alaska Native 77.8 20.7
White 144.9 21.2

Number of incidences and deaths per 100, 000 people
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Author:Rowe, Denise
Publication:Nevada RNformation
Date:May 1, 2014
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