“It’s a good news-bad news kind of thing. Good news is we caught it early. Not so great news is that it’s a little aggressive, so I’m going to be taking some time off to take care of this.”

This is how Al Roker, the veteran weatherman and co-host of the NBC Today Show, confirmed that he had been diagnosed with prostate cancer and will be undergoing surgery to have his prostate removed.

Roker explained that he wanted to publicly anncounce his diagnosis because he wants to help shine a light on the fact that black men are more likely to be diagnosed with prostate cancer (1 in 7 African American men, 1 in 9 men overall), present at an earlier age and are generally more likely to have locally advanced or metastatic disease at diagnosis.  In many cases they also have suboptimal outcomes to standard treatments.[1]

Overall, black men are have shorter progression-free survival (PFS) following treatment, while, at the same time, report more treatment-related side-effects that translates to the diminished health-related Quality of Life (QOL).[2]

A common cancer
Prostate cancer is the most common cancer in men. It is also the third most common cancer diagnosis overall (behind breast and lung). According to the U.S. National Cancer Institute’s SEER database, there will be an estimated 191,930 new cases (10.6% of all new cancers), and 33,330 deaths (5.5% of all cancer deaths) in 2020.

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However, these numbers do not neccessarily show the incidence and death rate of prostate cancer in different populations. For example, the incidence nedw cases per 100,000 persons is 175.2 for black men compared to 102.3 for white men. Furthmore, the risk of dying from prostate cancer is double for black men, compared to men of other races (37.4 vs 17.9 per 100,000 men).

In contrast, Asian American and Pacific Islanders have the lowest rates of death from prostate cancer among all races.

Disparities
The observed racial disparities in cancer are often complex, involving biological aspects, socio-economic, nutritional and socio-cultural determinants. They may also be impacted by age. For example, black men younger than 65 years of age have prostate cancer mortality rates nearly three times greater than that of white men.[3]

Nearly a decade ago, a study led by investigators from Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, found that black men with prostate cancer receive lower quality surgical care than white men. The racial differences persist even when controlling for factors such as the year of surgery, age, comorbidities and insurance status. [4]

Using an all-payer data set, the researchers analyzed records of 105,972 prostate cancer patients who received radical prostatectomies in non-federal hospitals in Florida, Maryland and New York state from 1996 to 2007. Of the patients, 81,112 (76.5%) were white, 14,006 (13.2%) were black, 6,999 (6.6%) were Hispanic and 3,855 (3.6%) represented all other races.

In this study, black men had 33% lower odds of using a high volume surgeon and 27% lower odds of visiting a high volume hospital than white men. Furthermore, black men had a higher rate of blood transfusion and longer length of stay in the hospital. They also were more likely to die in the hospital.

The findings of this study of racial variation in the quality of surgical care for prostate cancer added to previous studies that have shown racial differences in screening behavior, stage at presentation and use of aggressive treatment, suggest that black men may have more difficulty gaining access to high quality care. This may, in part, be explained by differences in access to high quality care, which in turn may reflect differences in patient resources.

Tumor-related vs. treatment-related characteristics
Examening the potential causes behind disparities, scientists at Vanderbilt University School of Medicine, and his colleagues examined information from the National Cancer Database, which includes cancer registry data from more than 1,500 facilities in the United States. The researchers sought to quantify the contributions of tumor-related and treatment-related characteristics, as well as factors related to access to care and disparities in prostate cancer survival among different groups.[5]

The analysis included 432,640 white, 63,602 Black, 8,990 Asian American and Pacific Islanders, and 21,458 Hispanic patients who underwent prostate removal between 2001 and 2014. The median follow-up time was 5.5 years, and the 5-year survival rates were 96.2%, 94.9%, 96.8%, and 96.5% for whites, Blacks, Asian American and Pacific Islanders, and Hispanics, respectively.

Adjusted the data for age and year of diagnosis, the researchers observed that Blacks had a 51% higher death rate than whites, while Asian American and Pacific Islanders and Hispanics had 22% and 6% lower rates, respectively.  Thenn, after adjusting for all clinical factors and non-clinical factors, the Black-white survival disparity narrowed to being 20% higher for Blacks, while the Asian American and Pacific Islanders-white disparity increased to being 35% lower for Asian American and Pacific Islanders. Overal, adjusting the factors had little effect on survival disparities between Hispanics and whites.

Among the factors and adjustments, education, median household income, and insurance status contributed the most to racial disparities. For example, if Blacks and whites had similar education levels, median household income, and insurance status, the survival disparity would decrease from 51% to 30%.

Socioeconomic status and insurance status are all changeable factors. Unfortunately, the socioeconomic inequality in the United States has continued to increase over the past decades.

Understanding these findings may help create public awareness that the racial survival difference, particularly between Black and white prostate patients, can be narrowed by erasing the racial inequities in socioeconomic status and health care.

Furthermore, effectively disseminating the findings may also be instrumental in helping public and policy makers close this gap, creating interventions aimed at improving access to high quality healthcare for all men, including access to high volume health care providers.

Screening or no screeing
The United States Preventive Services Task Force has, since 2012, recommended against prostate cancer screening for men of all races who have “average risk.” However, according to the Prostate Cancer Foundation, this recommendation has proven problematic, because Black men are at a statistically higher risk than white men of having prostate cancer. In contrast, the American Cancer Society recommends that most Black men men begin PSA screening at age 45 or age 40 if they have more than one first-degree relative who was diagnosed with prostate cancer at an early age. For white men at “average risk” the advise is to start screening at age 50.

The majority of prostate cancer is detected at a stage where cell changes are very localized. Bacause prostate cancer can be very slow-growing it may not cause a serious symptoms for years. That’s why many doctors suggest adopting a “wait-and-see” or active surveillance approach before attempting proactive therapeutic measures.

Vincent P. Laudone, MD, Chief of Surgery, Josie Robertson Surgery Center Clinical and an expert in robotic surgery for prostate cancer and bladder cancer at Memorial Sloan-Kettering Cancer Center, as explained on Today that in many men with low-risk or non-aggressive prostate cancer may benefit from active surveillance,

For Black man, including Al Roker, this approach may not neccessarily be the best advice, because in this population prostate cancer can become more aggressive earlier than in their white patients.

Active surveillance
Results from one, retrospective cohort, study published earlier this week in JAMA Network demonstrated that black men with low-risk prostate cancer, followed up for a median of 7.6 years, had a statistically significant increased 10-year cumulative incidence of disease progression and definitive treatment compared with non-Hispanic white men. The sudy included 8,726 men with low-risk prostate cancer.

The study showed a statistically significant increased 10-year cumulative incidence of disease progression (59.9% vs 48.3%) and definitive treatment (54.8% vs 41.4%), but, interestingly, not metastasis (1.5% vs 1.4%) or prostate cancer–specific mortality (1.1% vs 1.0%).[5]

Clinical trials and trust
In addition to improving access to healthcare, it is esssential to include Black men in clinical trials. To develop novel thereapies, and adequately establish the risks and benefits of treatments in Black populations, participatiuon of Black men in in clinical trial is essential. And while clinical trial participation may be a key to novel treastments,  participation requires trust.

Unfirtunately, a history of unscrupulous clinical trials has resulted that there is a lingering distrust and general lack of excitement among many Black men (and women) to participate in clinical trials .

Many Black patients cite the infamous Tuskegee Syphilis Study, conducted from 1932 to 1972 by the U.S. Public Health Service, in which clinical researchers knowingly withheld treatment from Black men with syphilis in order to study the progression of the disease.

Another unscrupulous example involves Henrietta Lacks, a black tobacco farmer and mother of five who died of cancer on October 4, 1951. Lacks’s cells, derived from cerevical cancer, were were taken without her knowledge and immortalized as the HeLa cell line, one of the most important tools which, over the past several decades, has contributed to many medical breakthroughs.

The case of Lacks’ cells is one of many examples of uninformed consent, leading to more distrust and and reluctance to partipation in clinical trials. To change this and increase the participation of Black people in clinical trials, serious trust building initiatives are needed to overcome existing trust issues and create a more diverse ethnic sample in clinical trials. The medical and research communities can contribute by developing clinical trials base on a proper understanding of the adverse histories without biases. Such an approach could increase the recruitment and retention of Black participants and improve the outcomes in those trials.

Al Roker’s desire to help shine a light on the fact that Black men are more likely to be diagnosed with prostate cancer, encouraging them to see a doctor and get the proper checkups to stop a cancer that is very treatable if detected early, may be one of many steps to help restore the trust of Black people in the medical community.

That is, indeed, “a good news… thing.”

Reference
[1] Smith ZL, Eggener SE, Murphy AB. African-American Prostate Cancer Disparities. Curr Urol Rep. 2017 Aug 14;18(10):81. doi: 10.1007/s11934-017-0724-5. PMID: 28808871.
[2] Chornokur G, Dalton K, Borysova ME, Kumar NB. Disparities at presentation, diagnosis, treatment, and survival in African American men, affected by prostate cancer. Prostate. 2011 Jun 15;71(9):985-97. doi: 10.1002/pros.21314. Epub 2010 Dec 28. PMID: 21541975; PMCID: PMC3083484.

[3] He T, Mullins CD. Age-related racial disparities in prostate cancer patients: A systematic review. Ethn Health. 2017 Apr;22(2):184-195. doi: 10.1080/13557858.2016.1235682. Epub 2016 Oct 5. PMID: 27706949; PMCID: PMC5573592.

[4] Barocas DA, Gray DT, Fowke JH, Mercaldo ND, Blume JD, Chang SS, Cookson MS, Smith JA Jr, Penson DF. Racial variation in the quality of surgical care for prostate cancer. J Urol. 2012 Oct;188(4):1279-85. doi: 10.1016/j.juro.2012.06.037. Epub 2012 Aug 16. PMID: 22902011; PMCID: PMC3770766.

[5] Wen W, Luckenbaugh AN, Bayley CE, Penson DF, Shu XO. Racial disparities in mortality for patients with prostate cancer after radical prostatectomy. Cancer. 2020 Sep 8. doi: 10.1002/cncr.33152. Epub ahead of print. PMID: 32895938.
[6] Deka R, Courtney PT, Parsons JK, Nelson TJ, Nalawade V, Luterstein E, Cherry DR, Simpson DR, Mundt AJ, Murphy JD, D’Amico AV, Kane CJ, Martinez ME, Rose BS. Association Between African American Race and Clinical Outcomes in Men Treated for Low-Risk Prostate Cancer With Active Surveillance. JAMA. 2020 Nov 3;324(17):1747-1754. doi: 10.1001/jama.2020.17020. PMID: 33141207; PMCID: PMC7610194.

Featured Image: Andrew Freedman, Science Editor at Mashable interviews Al Roker, Co-Anchor and Weather and Feature Anchor at TODAY in New York May 19, 2015. Photo Courtesy: © 2015 Insider Images/Andrew Kelly. Used with permission

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