Active surveillance for prostate cancer: Is it ready for primetime in the Caribbean?

The cancer epidemic in the Caribbean region: Further opportunities to reverse the disease trend

Cancer incidence has been rising in the Caribbean and is expected to have significant adverse implications for the health of people in the region and health systems in this decade. While developed countries, for the most part, enjoy the benefits of advanced technologies and adaptive systems in cancer control and management, a different experience confronts a large segment of the Caribbean population. The region has experienced some success in enhancing cancer services, however, there is a need to address gaps in several areas through nationally and regionally tailored initiatives. This Review complements previous publications on the challenges, actions, and progress towards cancer prevention and care in Caribbean countries but also further outlines potential positive impacts that can be derived from addressing gaps pertaining to cancer education, data management, screening and risk assessment, navigation services, gender factors, and resource development. The proposed approaches encapsulate concepts of health theories that are applicable across the ecological domains. When implemented in combination, the proposals may effectively contribute to reducing the cancer burden in the region.

Prostate Cancer in the Caribbean: A Baseline Assessment of Current Practices and Potential Needs

Afro-Caribbean men have a higher risk of prostate cancer than any other population of men in the world. However, the Caribbean is composed of a heterogenous group of healthcare systems located on small islands which makes population-based studies difficult to conduct and interpret. The aim of this review is to compile previously published data on the state of prostate cancer in Caribbean men and to highlight potential healthcare needs that can be addressed by public health efforts. We reviewed three databases and identified relevant papers that were subsequently searched by the authors. Peer-reviewed studies published in the English language after 2010 with a focus on prostate cancer diagnosis, management, and outcomes of Caribbean men were prioritized. Afro-Caribbean men were found to have a higher incidence and mortality rate compared to their counterparts. Misperception about the disease, lack of regional guidelines, and poor access to care are compounding factors that result in worse outcomes for these men compared to high-income nations. Urologists and oncologists in the region, while well-trained, are limited in number and in most cases do not offer newer treatment modalities. Overall, only a few island nations have cancer registries, and there remains a significant need for more population-based studies to assess guideline adherence and outcomes. Until further research and investment in the region is made, the disparity between the care received by Afro-Caribbean men and their counterparts will likely remain.

Comparison of Characteristics, Follow-up and Outcomes of Active Surveillance for Prostate Cancer According to Ethnicity in the GAP3 Global Consortium Database

BACKGROUND

Studies of active surveillance (AS) for prostate cancer (PCa) have focussed predominantly on Caucasian populations. Little is known about the experience of Asian men, while suitability for men of African descent has been questioned.

OBJECTIVE

To compare baseline characteristics, follow-up, and outcomes for men on AS for PCa, according to ethnicity.

DESIGN SETTING AND PARTICIPANTS

The study cohort included 13 centres from the GAP3 consortium that record ethnicity (categorised broadly as Caucasian/white, African/Afro-Caribbean/black, Asian, mixed/other, and unknown). Men with biopsy grade group >2, prostate-specific antigen (PSA) >20 ng/ml, T stage ≥cT3, or age >80 yr were excluded.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Clinical characteristics, follow-up schedules, outcome status, and reasons for discontinuation were compared across ethnic groups. Risk of upgrading, potential disease progression (grade group ≥3 or T stage ≥3), suspicious indications (any upgrading, number of positive cores >3, T stage ≥cT3, PSA >20 ng/ml, or PSA density >0.2 ng/ml/cc²), and conversion to treatment were assessed using mixed-effect regression models.

RESULTS AND LIMITATIONS

The eligible cohort (n = 9158) comprised 83% Caucasian men, 6% men of African descent, 5% Asian men, 2% men of mixed/other ethnicity, and 4% men of unknown ethnicity. Risks of suspicious indicators (hazard ratio = 1.27; 95% confidence interval [CI] 1.12-1.45), upgrading (odds ratio [OR] = 1.40; 95% CI 1.14-1.71), and potential progression (OR = 1.46; 95% CI 1.06-2.01) were higher among African/black than among Caucasian/white men. Risk of transitioning to treatment did not differ by ethnicity. More Asian than Caucasian men converted without progression (42% vs 26%, p < 0.001). Heterogeneity in surveillance protocols and racial makeup limit interpretation.

CONCLUSIONS

This multinational study found differences in the risk of disease progression and transitioning to treatment without signs of progression between ethnic groups. Further research is required to determine whether differences are due to biology, sociocultural factors, and/or clinical practice.

PATIENT SUMMARY

This international study compared prostate cancer active surveillance outcomes by ethnicity. Risks of upgrading and disease progression were higher among African than among Caucasian men. Transitioning to treatment without progression was highest among Asian men. Understanding of these differences requires further investigation.