Active surveillance and racial difference in risk

A new article in Urology (“the Gold journal”) suggests that African American men diagnosed with low-risk forms of prostate cancer may need to meet more stringent criteria than Caucasian Americans if they are to be appropriately managed on active surveillance protocols. Why? Because they appear to be at higher risk for disease progression.

The data in the article by Ha et al. in Urology is augmented by comment in a media release from The Cancer Institute of New Jersey.

Ha et al. set out to compare the clinical and pathologic findings of African Americans and Caucasian Americans diagnosed with prostate cancer who met standard criteria for active surveillance but actually underwent radical prostatectomy after discussion of their clinical options. To do this they used information from a prospectively maintained database that includes data on patients treated by radical prostatectomy at The Cancer Institute of New Jersey and at Johns Hopkins in Baltimore.

It does need to be understood, however, that this study is based on a retrospective analysis of the available data. In other words, it is a study in which one is being “wise after the event,” but we still don’t know whether we would get similar results if we tried to carry out such a study prospectively (by being “wise before the event”).

The criteria for including patients on active surveillance protocols vary from institution to institution. Therefore, in this study, the authors applied two widely applied sets of inclusion criteria — those developed by the University of California, San Francisco (UCSF) and those published by the National Comprehensive Cancer Network (NCCN). They then evaluated patients in their database according to the following protocol:

  • Did they meet the inclusion criteria specified by UCSF prior to surgery?
  • Did they meet inclusion criteria specified by NCCN prior to surgery?
  • What were their post-surgical pathologic characteristics?
  • What were the probabilities of pathological upstaging and Gleason upgrading post-surgery (compared to pre-surgical biopsy data)?

Here is what Ha et al. found:

  • Among the entire cohort of patients studied
    • 196 African Americans met UCSF’s eligibility criteria for active surveillance.
    • 191 Caucasian Americans met UCSF’s eligibility criteria for active surveillance.
    • 124 African Americans met NCCN’s eligibility criteria for active surveillance.
    • 148 Caucasian Americans met NCCN’s eligibility criteria for active surveillance.
  • African Americans had a higher probability of exceeding the maximum biopsy core criteria than Caucasian Americans according to both the UCSF and the NCCN criteria (15.3 to 20.4 vs. 11.5 to 15.0 percent, P <0.05, respectively).
  • African Americans were more likely to have multiple positive biopsy cores compared to Caucasian Americans (45.2 vs. 33.1 percent, P = 0.046) based on the NCCN criteria.
  • African Americans were upstaged (to ≥ pT3) more often than Caucasian Americans (19.4 vs. 10.1 percent, P = 0.037).
  • Age, preoperative PSA level, and number of positive cores were independent predictors of more advanced disease (upstaging and/or upgrading) among African Americans.

We do know that African American men appear to be at higher risk for progressive disease than Caucasian Americans when both are diagnosed with what otherwise appears to be a similar type of prostate cancer. We also know that genetic factors suggest clear differences between the risk for progressive disease among African Americans and Caucasians. It does make considerable sense, therefore, that African American males may want to be more cautious about acceptance of active surveillance as a management protocol than Caucasian men of similar age and clinicopathological characteristics. They may also want to be more aggressive about the actual active surveillance protocol under which they are managed (e.g., more frequent PSAs, annual MRIs and/or biopsies, etc.).

One Response

  1. Reasonable information to be passed on to African American physicians, clinics that are located in predominantly African American communities, prostate cancer support groups, and to African American men who monitor prostate cancer support lists.

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