St. Louis — In 1966, the Rev. Dr. Martin Luther King Jr. said, “Of all the forms of inequality, injustice in health care is the most shocking and inhuman.” While major advances have been made in health care, ethnic and racial disparities remain in the prevention, diagnosis and treatment of many illnesses, particularly prostate cancer.
The risks facing African-Americans are shocking: They have the highest incidence of prostate cancer and the highest mortality rate from the disease of any ethnic or racial group in the United States. One in six African-American men will develop prostate cancer in his lifetime, and one in 23 will die from it. The mortality rate is 2.4 times higher than that of the overall population. Indeed, the racial disparity related to prostate cancer is greater than for almost all other solid tumors.
Beginning in the 1990s, doctors began administering the prostate-specific antigen test, the most significant advancement in the diagnosis of prostate cancer. PSA is a protein secreted by prostate tissue and is easily measured with a simple blood test, allowing for early detection of prostate cancer.
Before the widespread use of PSA screening, advanced or metastatic prostate cancers constituted 25 percent of newly diagnosed cases in white men, and 50 percent in African-American men. These advanced-stage cancers remain difficult to treat and incurable. The most effective therapy includes lifelong testosterone-lowering drugs or castration, with all its grave side effects. Thankfully, with the widespread use of PSA screening, fewer than 5 percent of men with newly diagnosed cases are found to have metastatic prostate cancer.
Unfortunately, PSA is an imperfect screening tool. While an elevated PSA level may indicate prostate cancer, an abnormal blood test may occur for reasons unrelated to the disease and can also lead to the detection of prostate cancers that are unlikely to be life-threatening.
Guidelines from most medical organizations acknowledge these shortcomings and recommend that men weigh the benefits and limitations of PSA screening before deciding whether it is right for them.
Four years ago, however, the United States Preventive Services Task Force went further, recommending against routine PSA screenings for all men. This recommendation was based largely on the findings of two clinical studies that enrolled more than 250,000 men. The problem is that neither of these trials had enough black subjects to accurately assess the impact of screening in this high-risk population. This low rate of participation runs counter to a National Cancer Institute directive requiring adequate representation of minorities in clinical trials.
The government guidelines stunned doctors who recognize the greater dangers of prostate cancer in African-American men. Many believe that the disadvantages of routine PSA screening are outweighed when it comes to high-risk populations, and they worry that the guidelines will lead to less screening for men who might benefit the most from it. Their concerns have been borne out: Recent studies note a decrease in PSA screening for all populations, including African-American men.
Current screening techniques may have flaws, but that doesn’t mean they should be scrapped altogether, particularly for African-American men who develop prostate cancer at an earlier age. For them, the disease can be more aggressive, with double the mortality rate. Thanks to the routine use of PSA screening and improved therapies over the past 25 years, all racial and ethnic groups have experienced a decrease in mortality from the disease.
What’s needed, instead, is a smarter approach that incorporates the American Cancer Society’s recommendation that doctors and patients discuss the risks and benefits of PSA tests beginning at age 45 for African-American men, and at younger ages for men with a strong family history of prostate cancer.
The discussion should acknowledge that African-American men are at a higher risk of developing and dying from prostate cancer, that they have an increased risk for aggressive disease at diagnosis, that there are significant advancements in the detection and staging of prostate cancer, that the PSA test is just one of many available to help make an educated decision, and that the importance of seeking high-quality cancer care with supportive services and clinical trial opportunities are paramount.
In 2010 the Centers for Disease Control and Prevention began its Healthy People 2020 program, which among other things calls for a reduction of prostate cancer mortality by 10 percent, to 21.8 deaths per 100,000 men. But without a smarter approach to screening, this goal is unachievable for African-American men.
Amid our renewed national conversation about racial discrimination and equality, injustice in health care must be addressed directly. We can start by rethinking how we talk about and test for prostate cancer.
Lannis Hall is a radiation oncologist and minority outreach leader at Siteman Cancer Center, Barnes-Jewish St. Peters Hospital and the Washington University School of Medicine, where Arnold D. Bullock, Angela L. Brown and Graham Colditz are professors.