Elderly and black males at greater risk for aggressive disease?

An epidemiological analysis of data from the Surveillance, Epidemiology, and End Results (SEER) database shows that older and black males have higher risk for intermediate- and high-risk prostate cancer, but this may not be particularly surprising when one thinks about it.

Zhang et al., in another presentation reported at the Genitourinary Cancers Symposium, used the  SEER data to identify men with diagnosed with AJCC stage T1cN0M0 disease over the 5 years from January 1, 2004 and December 31, 2008. They then used statistical methods to model the probability of developing low-risk (PSA < 10 ng/ml and Gleason score ≤ 6), intermediate-risk (PSA from 10 to 20 ng/ml and/or Gleason score 7), and high-risk (PSA ≥ 20 ng/ml, and/or Gleason score ≥ 8) forms of prostate cancer.

Here are their findings:

  • 70,345 men with PSA-detected T1cN0M0 prostate cancer were identified in the SEER database and were duly evaluated.
  • Of these 70,345 men,
    • 47.6 percent had low-risk disease.
    • 35.9 percent had intermediate-risk disease
    • 16.5 percent had high-risk disease.
  • In men ≥ 75 years of age (compared to men of < 50 years of age)
    • The odds ratio (OR) for intermediate-risk disease was 4.4.
    • The OR for high-risk disease was 9.39.
  • Among black men (compared to white men)
  • The OR for intermediate-risk disease was 1.50.
  • The OR for high-risk disease was 1.84.
  • Men aged > 75 years accounted for
    • 11.8 percent of the entire set of men diagnosed
    • 24.3 percent of those diagnosed with intermediate-risk disease
    • 26.1 percent of those diagnosed with high-risk disease.

Now we already know that black men are, for a wide variety of possible medical and socioeconomic reasons, at higher risk than white men for a diagnosis of prostate cancer that leads to their death.

When we consider this group of white men of 75+ years of age in 2004 through 2008, they would all have been a minimum of 60 years of age in 1990 when the PSA test started to be widely used in the USA. They were therefore already at above-average risk at that time for a diagnosis of prostate cancer, and — being set in their ways — many of them may not have seen any reason to even talk to their doctor about a PSA test until they had symptoms of urinary problems.

By comparison, the younger males in this study, many of whom could have been as 35 years of age or younger in 1990, would have reached their late 40s and early 50s at a time when PSA screening was widely promoted, and may have gone on to have over-treatment for low- and very low-risk prostate cancer.

In other words, while we do not in any way dispute the findings reported by Hong et al., it is hard to justify the conclusion that older men are necessarily at higher risk today for more aggressive forms of prostate cancer than younger men based solely on this analysis. However, it is certainly true that the older one gets, the greater the likelihood that one will get diagnosed with some form of prostate cancer.

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