PROSTATE SPECIFIC ANTIGEN KINETICS AT TUMOR RECURRENCE AFTER RADICAL PROSTATECTOMY DO NOT SUGGEST A WORSE DISEASE PROGNOSIS IN BLACK MEN

Differences in treatment-based beliefs and coping between African American and white men with prostate cancer

The purpose of the study was to explore racial differences related to treatment-based beliefs (trust in physician, physician bias, access to care, and self-efficacy) and coping (religious coping and social support). The study was conducted in a 33-county area located in southwest Georgia (SWGA). Men living in SWGA and newly diagnosed with prostate cancer were invited to participate in the study. Men were also required to be 75 years of age or younger at the beginning of the study and free of dementia. In collaboration with the Georgia Cancer Registry, potentially eligible participants were identified through pathology reports. Participants completed three interviews during a 12-month period post-diagnosis. The 320 participants in this analysis ranged in age from 44 to 75 years with a mean age of 63 years, and 42% were African American. After controlling for confounders, African American participants were more likely to report physician bias, financial problems with access to care, and use of religious coping strategies. These results, based on a largely rural patient population, support those of other studies noting differences in perception of care, access to care, and coping strategies between African American and white men with prostate cancer.

Race, biochemical disease recurrence, and prostate–specific antigen doubling time after radical prostatectomy

BACKGROUND

Whether black men are at increased risk for biochemical disease recurrence after radical prostatectomy (RP) is debatable. Once black men have developed disease recurrence, it is unknown whether they have more aggressive disease than white men. To address this issue, the authors examined racial differences in pathologic features, time to disease recurrence, and prostate-specific antigen (PSA) doubling time (PSADT) among a cohort of patients treated with RP.

METHODS

The authors analyzed 953 white and 659 black men who were treated at 5 medical centers comprising the Shared Equal Access Regional Cancer Hospital (SEARCH) Database between 1988 and 2006. The association between race, adverse pathologic features, and biochemical disease recurrence was examined. Among those patients who developed disease recurrence, time to recurrence and PSADT were compared between the races.

RESULTS

Black men were on average 2.1 years younger (P < .001) and had higher median preoperative PSA levels (7.6 ng/mL vs 7.0 ng/mL; P < .001), yet presented with a lower clinical stage of disease (T1: 62% vs 44%; P < .001) and similar biopsy Gleason scores (P = .59). After adjusting for multiple clinical characteristics, black men were found to be as likely as white men to have adverse pathologic features (Gleason score >or=7, positive surgical margins, and seminal vesicle invasion) in the RP specimen and were less likely to have extracapsular extension (P = .03). Black men were more likely to have a biochemical disease recurrence (hazards ratio [HR] of 1.28; 95% confidence interval [95% CI, 1.07-1.54 [P = .006]). This increased risk was reduced slightly after adjustment for multiple clinical and pathologic features, and no longer achieved statistical significance (HR of 1.19; 95% CI, 0.97-1.45 [P = .09]). Among men who developed disease recurrence, the median PSADT was found to be similar among black men (17.0 months) and white men (14.6 months) (P = .26).

CONCLUSIONS

Despite presenting with earlier clinical stage and similar pathologic features at RP, black men were found to be at a slightly increased risk for biochemical disease recurrence. However, these recurrences appear to be no more aggressive than those found in white men.

Minority issues in prostate disease

This article has discussed the increased incidence and disproportionately increased mortality of prostate cancer among African American men.Although the exact reasons are unknown, genetics may play a role, in addition to health care practices. Morbidity from other disease states, such as diabetes, obesity, or hypertension, may influence the overall survival of patients with prostate cancer. Current research tools will continue to explore biologic differences between the races; however, socioeconomic status and access to health care must not be overlooked. Several studies have demonstrated that similar disease stages and equal access to health care will result in similar outcomes. It is recognized that screening for prostate cancer will remain a controversial topic. Several influential professional societies recommend against screening and other professional societies endorse screening. Large-scale trials are currently underway hoping to answer this critical question. Since the advent of current screening tools, however, it seems that the overall mortality for prostate cancer has decreased and this cannot be ignored. Certainly, screening programs and clinical trials have traditionally had difficulty in recruiting minority participants, although more recent trials seem to be finding success. A primary care physician who is viewed as competent by their patients can certainly have a positive impact on their African American patients' willingness to participate in studies and screening programs. Most importantly, on the individual level, primary care physicians can provide a great service to their minority patients by offering educational materials on prostate cancer and by offering screening to qualified patients. The current American Urologic Association and National Cancer Institute guidelines recommend offering screening to all men age 50 and above. African American men or men with a first-degree relative with prostate cancer should be offered screening beginning at age 40. Proper screening consists of both a digital rectal examination to assess for asymmetry or nodules of the prostate and a serum PSA. Current recommendations are that individuals with a serum PSA greater than 4 ng/mL ora prostate nodule or asymmetric prostate should be referred to an urologist,where a biopsy can be performed easily in the office setting.The PSA cutoff of 4 has recently been questioned. A study by Thompson et al [31] evaluated 2950 men with a PSA of 4 or less with prostate biopsy.They found that the risk of prostate cancer in men with a PSA between 3.1 and 4 was 26.9% and that 25% of these men with prostate cancer had high-grade disease. All men found to have cancer had T1 disease. The clinical relevance of this surprisingly high rate of prostate cancer in men with a normal PSA is yet to be determined and is pending in studies on the ultimate effect of screening on mortality from prostate cancer. This information is not intended to confuse the issue, but intended to provide the most up-to-date information and allow for the best clinical decision making by the primary care physician. What can currently be recommended is if a patient is concerned about his possibility of having prostate cancer despite a normal PSA, a referral to an urologist to at least further discuss the issue may be in order. This may be especially true if the patient is African American or has a family history of prostate cancer at an early age.