Closing the Gap in Prostate Cancer Outcomes for Black Men

Benjamin Garmezy, M.D.

Credit: SCRI

Prostate cancer is the most commonly diagnosed cancer in men — but for Black men, the risks are even greater. Recent high-profile diagnoses among younger, seemingly healthy Black men have sparked urgent conversations about why this disease affects Black men more often and more aggressively than other groups. While genetics play a role, so do access to care, screening practices and environmental factors — making awareness and early action critical.

To help patients and families better understand what’s driving these disparities and what steps can be taken to protect their health, The Educated Patient spoke with Benjamin Garmezy, M.D., and Manojkumar Bupathi, M.D., M.S., leaders in genitourinary cancer research at Sarah Cannon Research Institute (SCRI). They discuss why Black men face higher risks, how screening guidelines are evolving, the importance of diverse clinical trial participation and what families can do to advocate for early testing and better outcomes.

Manojkumar Bupathi, M.D., M.S.

Credit: Rocky Mountain Cancer Centers

Recent high-profile diagnoses of prostate cancer in relatively young, healthy Black men have raised awareness — can you explain why prostate cancer disproportionately affects Black men?

Benjamin Garmezy, M.D.: First, more research is needed in this area, but there are a few different reasons we are aware of. Historically, there has been a concern that Black men are not being screened as frequently as other populations, and there are disparities in their access to care as well as potential barriers in the way certain providers and patients interact.

Second, there is a genetic component. Black men seem to develop more aggressive prostate cancers and earlier in their lives than other men. That might be because BRCA [gene] mutations have the potential to run more prevalently in Black men than in other populations, which can lead to higher-risk cancers.

Manojkumar Bupathi, M.D., M.S.: Yes, genetics are a factor, and another is difference in environmental exposures. There are dietary, metabolic and environmental differences influenced by socioeconomic status. All of these can potentially impact the aggressiveness of the cancer as well. Often there are some differences in androgen signaling in different races, so that can also contribute to the different biology and aggressiveness in prostate cancer.

What are the key risk factors that families and individuals should know about? Are there early signs or symptoms that might appear before routine screening that would detect prostate cancer?

MB: A big risk factor for prostate cancer is the family history of cancers. As Dr. Garmezy mentioned earlier, BRCA mutations are key indicators for breast, ovarian and prostate cancer, so people who have a family history of any of these cancers should know they are at risk. Symptoms that point to a diagnosis include blood in urine, increased frequency and urgency of urination (especially at night) — all things that are easy to dismiss as “nothing.”

BG: Unfortunately, a lot of early signs of prostate cancer are nonspecific. They mimic urinary tract infections and normal growth of the prostate as men age, called “benign prostatic hyperplasia.” As Dr. Bupathi indicated, often these symptoms get overlooked or dismissed. If you are having these symptoms, the prostate-specific antigen (PSA) screening test becomes even more important.

MB: A PSA test is a blood test used to screen for prostate cancer. It shows if there are any kind of internal markers that would indicate a need for further testing, like imaging or biopsy. Often when patients see their PSA levels, they think it is in a normal range and assume they are OK, but there is a thing called “PSA velocity,” which is the change in your PSA number over time. Patients need to understand that if there are increases in PSA every year, that does not necessarily mean that things are normal.

How have recent guidelines for prostate cancer screening evolved for Black men?

BG: Screening in general for this disease can be controversial. The U.S. Preventive Services Task Force actually took away their recommendation and instead are pushing shared decision-making. They did this due to concerns of overtreating and overdiagnosing nonlethal prostate cancer. Remember, the majority of prostate cancer is nonlethal and can just be watched. This is of critical importance — most prostate cancer is something you just live with, and you just watch it.

We do know that the Black population develops these cancers earlier and they seem to be more aggressive, so screening for Black men should start five to 10 years earlier on average than other populations of men. Black men should consider starting screening at around [age] 45. Some guidelines even suggest 40 with a yearly PSA test. There are many different guidelines out there, and they all have slightly different recommendations. I recommend talking to your primary care provider or your urologist if you have family history of prostate cancer, and for Black men, consider screening starting at 40 or 45.

Why is diverse and inclusive enrollment in clinical trials so important for improving outcomes?

MB: Cancers are heterogeneous (all different), and we know that we are all heterogeneous, too. With any new drug, we see huge variation in patient responses, and it is usually the patient’s biology that makes that difference. Ethnicity does make a difference in overall response to drugs as well. For example, in lung cancer, you will find young, female, Asian nonsmokers to have more estimated glomerular filtration rate (eGFR) alterations and higher rates of that type of cancer. We only know that because of the broad patient populations studied throughout the clinical trial development. So, to understand and advance the science, we need to have a diverse population to understand what therapies are going to work for which group of patients.

BG: And it is not just cancer. For example, we know in treating hypertension certain regimens for blood pressure work better in certain populations than others, thinking about the differences between historically Black and historically White populations. Clearly, the way drugs get metabolized (the way therapies get to their targets within the body) are going to act differently in some patients based on racial backgrounds. There are some groups doing that now — looking at differential effects on certain therapies in prostate cancer between White and Black populations, and I think that work is critical. It is in its infancy, and I think we are going to see more emphasis over the next 10 years. But it is going to take a lot of time, a lot of work, a lot of volunteers, and a lot of men with prostate cancer to see the value in joining those registries so that they can help men in the future and learn from their disease and their journey.

How can families advocate for appropriate and timely screening if they have a history of prostate cancer?

BG: We know that men are less likely to seek out medical care. They often do not have a primary care doctor. They are not getting screened. They are not getting blood pressure screening or cholesterol screening or anything. But if you have a family history of prostate cancer, not only do you need to be doing all the routine things, you also need to be talking to a doctor about PSA screening. It is a very simple test that can help save lives.

MB: Generally, when screening for cancers, we recommend an individual get started on screenings about five to 10 years earlier than when the youngest person in their family got diagnosed. We have seen patients get diagnosed in their late 30s with prostate cancer as well, though it is less common.

What steps can Black men and their families take now to reduce their risk or detect prostate cancer early?

MB: Screenings and having regular conversations with your primary care provider.

Is there any area of research that you are particularly excited about/want patients to know about their treatment options?

BG: If you are diagnosed with prostate cancer, you do not necessarily need treatment. Knowledge is power, so we do not want to be fearful of getting the diagnosis. That way we can do something called “active surveillance” and really monitor on a yearly basis what is evolving in the blood.

Our goal is that men with prostate cancer live well without side effects because we can safely monitor cancer in the majority of them. Unfortunately, there are going to be some men who are diagnosed with a potentially lethal localized prostate cancer — something that is a higher grade, more aggressive tumor. Those patients are treated with surgery or radiation. Those are historic options, but we’re now better able to stratify who needs more intense therapy versus less intense therapy. We can now shorten the interval of radiation to only a few days versus five to six weeks, which has been done historically.

If we find metastatic cancer, which is rare, our treatments have gotten significantly better. Patients can live for many years with metastatic prostate cancer. Sometimes it is with hormonal therapy, but other times we might even be able to spare that with some of the newer clinical trials that are emerging, like those with special radioligand therapy, which combines infusions of radioactive particles or other modalities with potentially immune-based treatment paradigms. So, I would say the landscape is completely shifting.

Garmezy is associate director of Genitourinary Cancer Research and executive co-chair of the Genitourinary Cancer Research Executive Committee at SCRI.

Bupathi is president of the Rocky Mountain Cancer Centers and executive co-chair of the Genitourinary Cancer Research Executive Committee at SCRI.