Several decades of data show that Black men are less likely to be screened and treated for prostate cancer than their white counterparts. In this interview, Kelvin A. Moses, MD, PhD, discusses the reasons for these disparities, potential genetic, cultural, and environmental factors, new data showing improved outcomes in Black men receiving certain treatments, and how practicing urologists can address prostate cancer disparities. Dr. Moses is associate professor of urology at Vanderbilt University Medical Center, Nashville, TN.
Dr. Moses was interviewed by Urology Times Editorial Consultant J. Brantley Thrasher, MD, executive director of the American Board of Urology, Charlottesville, VA.
Why do you think there’s still a large disparity between African-American and white men when it comes to prostate cancer survival?
It’s been persistent for decades, and there are a lot of factors that go into it. During the PSA screening era—from the late 1980s to 2012 or so—the gap did narrow some. That was likely due to some increased screening and better treatments. But overall, there’s been a disparity in screening, and among men who are diagnosed, a disparity in treatment; Black men are less likely to get treated overall. Insurance, socioeconomic status, and cultural factors all play a role, but the lion’s share of the disparity comes from the factors that we as urologists have some control over.
One of my African-American patients told me that reaching out to the wives of patients to encourage screening is important. What are your thoughts about that?
I really support that, and I think it’s very important. It’s an effort that I’ve done, as have Dr. Isaac Powell in Detroit, Dr. Willie Underwood in Buffalo, and Dr. Mark Litwin in Los Angeles, among many others. One of the best methods of community engagement is to involve men who are at risk, as well as their partners and loved ones. It’s very effective.
Bringing in the wives and partners helps because sometimes men are a little fearful or resistant, and having the people who love you encouraging you to seek out health information is very important. Sometimes there is a barrier or a mental hurdle about visiting a large academic center or hospital, and that outreach breaks down the barrier so you can start a conversation about screening.
Do you think there is still a bit of skepticism—a “Tuskegee effect”—among African-American men and a perception that “I’m being experimented on”?
Absolutely. There’s a cultural memory that’s attached not only to Tuskegee, but also to the history of separate and unequal facilities, segregated hospitals, and not being able to get to a doctor until it’s too late. There’s been research on perceptions about surgery and spreading cancer, and that perception largely comes from people who do not have access to appropriate health care and can only obtain care on an emergent basis. By the time they get to surgery or even imaging, it’s too late, and it seems as though the surgery was the problem when really it was the access and the barriers that preceded it.
As my generation is now entering our 40s and 50s and our parents are moving on, we’ve been able to dispel some of the mythology, but barriers to adequate health care definitely remain.
Don’t we still see, though, some real disparities, even in an equal-access system like the military or the VA?
You do, but it’s not as glaring a difference. Dr. Steve Freeland’s group has published several papers showing at least almost equivalent outcomes, maybe a little worse in Black men, and that’s where the genetic/biologic aspect comes into it. A study I did with Dr. Karim Touijer examined younger men who underwent surgery for prostate cancer and the pathologic outcomes were nearly similar, with slightly higher risk of biochemical recurrence. But overall, equal treatment can yield almost equal outcome. The VA and states that have participated in Medicare exchanges through the Affordable Care Act can approach much more equitable outcomes.
We’ve often heard data quoted that African-American men present with prostate cancer at an advanced stage and an earlier age. Do you still think that that’s the case, and if so, how do you counsel men when you talk to them about prostate cancer?
It absolutely is the case, and the population-level data support that. SEER data have shown that Black men present at an earlier age and have higher risk and higher grade disease. The National Cancer Database and CaPSURE show similar findings.
I have recommended that we follow what are now the revised USPSTF guidelines or NCCN guidelines and start screening for prostate cancer earlier in Black men, just like we do in patients with first-degree relatives. Specifically, I believe screening should start somewhere around age 40 or 45.
In addition, there is an important aspect to consider known as environmental racism, where there are structural aspects of our society where Black and poor populations are more likely to live near an oil refinery or Superfund site or chemical plant. Those increase the risk of cancer, there’s no doubt about it. Environment does play a role, and genetics plays a role.
Taking all that together, I encourage men to be vigilant about getting screened for prostate cancer earlier, particularly if they have a family history. So many men who come into my clinic and tell me their dad died of bone cancer; it is more likely prostate cancer that spread and they just didn’t know it.