Transcript P - The Prostate Health Education Network

Prostate Cancer Screening in
African American Men
Mark H. Kawachi, MD FACS
Director, Prostate Cancer Center
City of Hope, National Medical Ctr
Prostate Cancer Early Detection
• The National Comprehensive Cancer Network
(NCCN) is an alliance of 21 of the world’s
leading cancer centers.
• NCCN guidelines are widely recognized by
oncology clinicians and payors.
• Where possible, the cancer guidelines are
evidence-based.
Definition of “Screening”
• No universally accepted definition.
• Generally thought of as a method of applying a
test to an at-risk population to determine the
presence or absence of a particular disease.
• Utilizing this (or similar definition) ignores or
discounts the individual’s ability to participate
in the decision making process.
Prostate Cancer Early Detection
• The prostate cancer early detection guidelines
stress the importance of involving the patient
and informing him of the implications and
potential consequences that may arise from the
decision to embark on an early detection
pathway.
• As such the pro’s and con’s of the early
detection algorithm are thoroughly discussed.
Overview of AA Cancer Dilemma
in the USA
• The age adjusted cancer related mortality in
the USA is 1.4 times higher for black men than
for white men.
• The disparity is greatest for prostate cancer, for
which incidence rates are 1.7 times and
mortality rates 2.4 times higher for black men.
Overview of AA Cancer Dilemma
in the USA
• In the Medicare pt population, this is further
quantified with a 1.8-year shorter survival for
black men with localized CaP treated with
surgery, 0.7 years shorter after radiation
therapy, and 1.0 years shorter for watchful
waiting. These findings persist even after
accounting for covariates including education
and income levels.
What’s the Difference
• Genetic predisposition?
• Differences in tumor initiation, promotion, and
progression?
• Differences in higher fat diets, higher
testosterone exposure/levels, or higher BMI?
• Structural, financial, and cultural differences to
screening, early detection, or aggressive
therapy?
• Physician bias?
There May Be Reason for
Optimism in the USA
• There is data, that now suggests that in the
PSA era, that the organ confined disease rate is
increasing, and that the disparity in the
mortality is lessening.
• It would also appears that stage for stage the
same high cure rates can be achieved in black
men as in their white counterparts
Family Hx and CaP Risk
Bostwick, Cancer 2004:101(10Sup):2371
Bratt J Uro 2002; 168:906
Morganti,Acta Genet Stat Med 1956-1957; 6(2):304
AA CaP Incidence
USNIH SEER data accessed 2008
AA CaP Mortality By Age
Powell, J Urol 171,1508,2004
AA Mortality: Organ Confined vs
Non-Organ Confined
Powell, J Urol 171,1508,2004
AA Recurrence: Before and After
1996
Bianco, J Urol, 168, 479, 2002
AA CaP Recurrence By Dates
Bianco, J Urol, 168, 479, 2002
AA CaP Recurrence By Dates
Catalona, J Urol, 168, 1980, 2002
AA CaP Recurrence By Dates
Catalona, J Urol, 168, 1980, 2002
Impact of Race on CaP Outcomes
Cross, JCO, 20, No12, 2002, 2863
Summary
• At present the evidence does not suggest that
the biology of prostate cancer in black men
differs from that of any other group in any
identifiable or clinically meaningful way.
• In fact, recent data suggests similar cure rates
for organ confined disease.
• Therefore, the data would imply that race
should not influence the decision on the need
for initial or subsequent prostate biopsy or the
decision for or choice of therapy for any stage
of prostate cancer.
Conclusion
• It is intuitive to think that early detection of
prostate cancer will lead to earlier and more
effective therapies; however there is limited
evidence to support this statement.
• For men who choose to be screened by digital
rectal examination and PSA, those in the
highest risk groups (AA/family history) should
begin at a younger age (eg 40 years) than those
of average risk.
Conclusion
• Despite the absence of known biological
differences or firm evidence of a beneficial
effect of screening on mortality, these
recommendations seem prudent in the face of
the higher age adjusted incidence and
historical mortality rates for organ confined
cancers in AA men in the USA.
Conclusion
• Future studies to help clarify the relationship
between histologic and clinically evident
prostate cancer and the true effect of PSA
screening on prostate cancer mortality are
necessary.