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The disparities in prostate cancer are striking. In the United States, Black men continue to experience a far greater incidence of new prostate cancers and are 2.2 to 2.5 times more likely to die from the disease than any other racial/ethnic group. Taking action to close these gaps is an imperative for moving toward equitable cancer care.
ACCC has several resources available for the cancer care team treating patients with prostate cancer, including an online course on emerging therapies for the management of castration-sensitive prostate cancer and a new project addressing disparities in caring for patients with prostate cancer.
The disparities in prostate cancer are striking. In the United States, Black men continue to experience a far greater incidence of new prostate cancers and are 2.2 to 2.5 times more likely to die from the disease than any other racial/ethnic group.1,2 Taking action to close these gaps is an imperative for moving toward equitable cancer care.
Multiple factors contribute to these disparities. Among them are social determinants of health, unequal healthcare access, and, potentially, tumor biology, according to the authors of a recent review article, “Racial Disparity in Prostate Cancer in the African American Population with Actionable Ideas and Novel Immunotherapies.” Ashutosh K. Tewari, MD, Sujit S. Nair, PhD, and their colleagues in the Department of Urology at Icahn School of Medicine at Mount Sinai in New York City authored the article. In it, they highlight recent research focused on molecular and genomic differences in prostate cancer in Black men, and they discuss the outlook for improving outcomes through better integration of clinical and genomic data for diagnosis, prognosis, and treatment planning.
Acknowledging the potential for precision medicine approaches to close the prostate cancer disparity gap, the authors mention recent studies that suggest that “when socioeconomic differences are removed, prostate cancer mortality rates for AA [African American] and Caucasian men are similar.”2-4 While it will take time for new knowledge about the differences in prostate tumor biology and clinical applications to mature, providers can take immediate steps toward eliminating some of the drivers of disparities in prostate cancer care by addressing the socioeconomic differences that can cause them.
In their article, Dr. Tewari, Dr. Nair, and their colleagues suggest several actions for improving early diagnosis and potentially reducing the incidence and mortality of prostate cancer in American Black men. These include:
Potential strategies to reduce disparities in prostate cancer may include prostate-specific clinics for Black men; prognostic tools that are specific to Black men with prostate cancer starting active surveillance; exercise, smoking, and nutrition interventions; and the development of MRI imaging protocols specifically for this patient population. Strategies to manage comorbidities may include controlling diabetes, reducing obesity, and using mind-body interventions to promote well-being.
To learn more about the work to reduce disparities in prostate cancer at Mount Sinai, ACCCBuzz spoke with Dr. Tewari, professor and system chairman of the Milton and Carroll Petrie Department of Urology at the Icahn School of Medicine at Mount Sinai, about his passion for closing the gap in prostate cancer detection and treatment. We also addressed a new initiative Dr. Tewari is spearheading to bring mobile prostate cancer screening, advanced imaging technology, and prostate cancer education to some of the New York City neighborhoods hardest hit by the COVID-19 pandemic.
ACCCBuzz: How did your interest in prostate cancer—and disparities in prostate cancer—come about?
Dr. Tewari: Early on, I was in Michigan, where 40 percent of the men with prostate cancer were Black men. And I felt that this was my calling. I am dealing with an actionable problem. There is 2.2 times more mortality among men of color with prostate cancer. There is something that is changeable here.
I am the same surgeon. I am the same physician. I am the same scientist. But which patient group I see has an impact. I have been in New York City for 17 years now. On the Upper East, one mile on one side in Harlem, there could be a different prostate cancer mortality rate than one mile on the other side, downtown.
ACCCBuzz: There is ongoing concern about the impact of the COVID-19 pandemic on delayed doctor visits and cancer screenings, which means cancer care providers will be seeing more late-stage cancers. Is that correct?
Dr. Tewari: Yes. If someone is worried about COVID-19, that can override their concerns about getting cancer. They’re focused on challenges with COVID-19, so they’re not thinking about prostate cancer.
ACCCBuzz: What impact does variable access to care have on prostate cancer rates?
Dr. Tewari: There are molecular differences between the two ethnic groups [i.e., Black and non-Hispanic Whites] in terms of prostate cancer, but molecular differences can be overcome if the same cancer is caught at the same time and at the same stage. But if the delay in presentation leads to a delay in diagnosis for four or five years, the same cancer is more lethal. When access to healthcare is the same, there tends to be similar outcomes.
ACCCBuzz: Your article on prostate cancer disparities addresses a drop in the enrollment of Black men into prostate cancer trials in the US from 11.3% in 1995 to 2.8% in 2014. What needs to happen to improve clinical trial enrollment by Black men?
Dr. Tewari: It’s a multi-layer, socio-medical issue. I’m not an expert on the social issues, but I do think we need to make enrollment easy, make it understandable, make it trustworthy, and it’s important not to give up. If men don’t want to come to us, we go to them. Some community approaches can help increase the number of people who enroll into these clinical trials. I think that step one is to build trust. Step two, make it easier to enroll. Step three is to take into consideration who is talking to the men about clinical trials. If someone from their community is talking to them, they are more likely to listen or trust that individual.
ACCCBuzz: What is the process for diagnosing prostate cancer?
Dr. Tewari: Basically, it involves taking a regular history; asking about the person’s family history of prostate cancer, breast cancer, pancreatic cancer, and any other cancers; giving a blood test; and conducting a PSA [prostate-specific antigen] test. A digital rectal exam is given, and then the patient is triaged based on whether or not a biopsy is needed. That is where we want to introduce imaging to help in making the decision to biopsy and to be targeted and effective in determining if there is cancer.
Over the years, we have seen significant progress in the field of biomarker discovery, and a wide array of biomarkers are being tested, including urine-based biomarkers like PCA3 (Progensa™ PCA3 Assay and ExoDx™ Prostate Test); an exosome-based assay of PCA3 and ERG levels (MiPS assay and SelectMDx®); and a qRT-PCR assay, which measures mRNA levels of HOXC6, DLX1 and TDRD1 genes.5
There is data that suggests that men of color tend to have a little bit higher incidence of cancer that is in the front of the prostate—what we call transition zone cancer—so an anterior cancer. The fact that it is away from the back side of the prostate is very amenable for an exam and very amenable for a biopsy coming from that side. These patients have a “hidden zone,” meaning that imaging can unmask their cancer. It’s not that any patient with prostate cancer cannot benefit from imaging, but these individuals have an even greater likelihood of benefiting from it.
Risk stratification can be done based on patients’ PSA levels, the digital rectal exam findings, and MRI findings. The important discussion happens afterward. If I have to give a patient a diagnosis of cancer, I tell them whether their cancer is a lethal one or an indolent one. I tell patients that it is like a tiger cub, a toothless tiger, or a man-eating tiger. For some patients, active surveillance is an option. And there are some patients who can be cured by one modality. Then there are patients who need multi-modality treatment and enrollment in a clinical trial. A combination of biomarker, exam, and imaging gets us within an 80 percent certainty of knowing whether a cancer is lethal or not.
ACCCBuzz: Mount Sinai recently received a $3.8 million donation to launch an initiative to improve access to care for Black men in NYC boroughs that have faced a significant burden from the COVID pandemic—Queens, the Bronx, and Harlem. What is your approach to this program?
Dr. Tewari: I’m very practical-minded. I felt that if these individuals are not coming to us, and I’m not going to wait. I’m going to send something out into the community, and fight the battle in the trenches right there.
Dr. Tewari is the professor and system chairman of the Milton and Carroll Petrie Department of Urology at the Icahn School of Medicine at Mount Sinai. He also serves as director of the Center of Excellence for Prostate Cancer at the Tisch Cancer Institute and as director of the Lizzie and Jonathan Tisch Center for Prostate Health. A surgeon scientist, Dr. Tewari leads a multidisciplinary team committed to improving prostate cancer treatment using clinical trials, state-of-the-art research, and education.
Stay tuned for updates on the Mount Sinai initiative, which will bring a mobile unit with advanced imaging technology to communities in New York City that have been hit hard by COVID-19. The program, scheduled to launch late summer 2021, will bring prostate cancer education and screening to men where they live.
References
1. Centers for Disease Control and Prevention and the National Cancer Institute. U.S. Cancer Statistics: Data Visualizations. Available online at: www.cdc.gov/cancer/dataviz. Data published June 2020.
2. Dess RT, Hartman HE, Mahal BA, Soni PD, et al. Association of black race with prostate cancer—specific and other-cause mortality. JAMA Oncol. 2019;5(7):975-983.
3. Riveiere P, Luterstein E, Kumar A, Vitzhum LK, et al. Survival of African American and non-Hispanic white men with prostate cancer in an equal-access health care system. Cancer. 2020;126(8):1683-1690.
4. Tewari AK, Gold HT, Demers RY, Johnson CC, et al. Effect of socioeconomic factors on long-term mortality in men with clinically
localized prostate cancer. Urology. 2009;73(3):624-630.
5. Kohaar I, Petrovics G, Srivastava S. A rich array of prostate cancer molecular biomarkers: opportunities and challenges. Int J Mol Sci. 2019;20(8):1813.