What patients think and understand can impact their decisions and their outcomes


It has long been appreciated that African-American males have higher risk for diagnosis with prostate cancer, and higher risk for prostate cancer-specific mortality, than those of other ethnic origins living in the US. It has also long been suspected that African Americans may receive less aggressive treatment for prostate cancer than comparable white patients with the same types of prostate cancer, and that this may contribute to the increased risk for prostate cancer-specific mortality.

A newly published paper by Gordon et al. from the University of North Carolina at Chapel Hill has made a new attempt to explore factors that may influence prostate cancer treatment decisions made by African-American and white males.

Gordon et al. set out to prospectively enroll men newly diagnosed with non-metastatic prostate cancer between 2011 and 2013 prior to their treatment. They were able to enroll a total of 1,170 newly diagnosed patients and carried out a one-on-one phone survey with each of these patients, in which the patients were asked:

  • To rate the aggressiveness of their prostate cancer
  • To rate the importance of 10 factors affecting their treatment decision-making process

Each of the individual patient’s rating of the aggressiveness of his cancer was double-checked against his actual diagnosis by reviewing that individual’s medical record. The actual aggressiveness of each patient’s cancer was categorized according to the National Comprehensive Cancer Network (NCCN) guidelines.

Here are the core findings of the study:

  • Of the 1,170 patients enrolled
    • 304 were African American
    • 866 were white
  • Among the African-American patients
    • 120/304 (39.9 percent) had low-risk disease
    • 124/304 (41.2 percent) had intermediate-risk disease
    • 57/304 (18.9 percent) had high-risk disease
  • Among the white patients
    • 443/866 (52.1 percent) had low-risk disease
    • 307/886 (36.1 percent) had intermediate-risk disease
    • 101/866 (11.9 percent) had high-risk disease
  • The African-American patients were, on average, slightly younger (by 3 years) than the white patients.
  • There were also significant differences between the two groups in relation to such factors as educational level, insurance coverage, marital status, household income, and employment status.
  • Among the African-American patients
    • 80.3 percent of those with low-risk forms of prostate cancer rated their cancer as “not very aggressive”.
    • 53.9 percent of those with high-risk forms of prostate cancer rated their cancer as “not very aggressive”.
  • Among the white patients
    • 77.6 percent of those with low-risk forms of prostate cancer rated their cancer as “not very aggressive”.
    • 24.0 percent of those with high-risk forms of prostate cancer rated their cancer as “not very aggressive”.
  • African-American and white patients both indicated that a cure was a “very important” decision-making factor, but …
  • African Americans were significantly more likely than white patients to consider cost, treatment time, and recovery time as “very important”.
  • In a multivariable analysis, accurate perceptions of cancer aggressiveness and of cure as the most important factor affecting treatment decisions were significantly associated with
    • Actually receiving any aggressive treatment
    • Selection of surgical treatment (as opposed to radiation therapy).
  • After adjustments for these factors and sociodemographic factors, race was not significantly associated with the treatment actually received.

Gordon et al. conclude that

Racial differences in perceived cancer aggressiveness and factors important in treatment decision making provide novel insights into reasons for the known racial disparities in prostate cancer as well as potential targets for interventions to reduce these disparities.

It appears to be very clear from this study that misperceptions about the aggressiveness of the patient’s cancer and greater concerns about specific socioeconomic factors may be key drivers of the higher level of prostate cancer-specific mortality among African Americans compared to white patients. While this is by no means a “revolutionary” finding, the confirmation of this in a relatively large, prospectively enrolled cohort of newly diagnosed men in a specific geographic area does most certainly raise issues with regard to how best to address these two issues.

It is worth noting that, many years ago now, Dr. Judd Moul and colleagues showed that, within the US Military, in which all patients received similar forms of care for prostate cancer, regardless of race and ethnicity, the outcomes of treatment were no different between African Americans and whites. In that particular set of men, issues like cost of treatment, treatment time, and recovery time would very likely have shown no difference between the racial groups.

Editorial note: The “New” Prostate Cancer InfoLink thanks Ronald C. Chen, MD, of the University of North Carolina at Chapel Hill, for providing us with the full text of this paper for review.

7 Responses

  1. You mean if I can’t afford it, I might tell myself I don’t need it?

    Reminds me of the debate we had about “self identity” studies not being genetically based.

  2. It is disconcerting to note that both white and black men rated their high-risk forms of prostate cancer as “not very aggressive!”

  3. Dear Michael:

    I cannot read minds. I wrote what I meant, as did the research team.

  4. Dear Chuck [maack1]:

    I think it might be more accurate to say that, ‘It is disconcerting to note that both some white and many more black men rated their high-risk forms of prostate cancer as “not very aggressive!”’

    Unfortunately, as you well know, men don’t always “hear”, with accuracy, what they are told. Ask any woman! However, there may be other factors that also impact this particular issue among the male members of African-American community.

  5. Something to think about is the basis for identifying subject’s race. As I understand the genetic debates, it is surprisingly difficult to identify race by genetic differences. That leaves self-identification of race as the basis of racial identity. Obviously that introduces some fuzziness into conclusions about the impact of race on care, outcomes, etc.

  6. My doctors tell me, “You gonna die!” I heard that.

  7. “Race” and “ethnicity” are not the same thing as genetics at all.

    In the early days of the American west, there are numerous tales of “white” children being abducted and brought up by native Americans and becoming fully integrated into specific tribes over long periods of time. Clearly these children had very different genetic ancestry, but they were brought up over years to eat, think, behave, and prioritize issues in ways that would have been utterly foreign to their genetic relatives.

    What “race” did these did these children become? They may well have been genetically English or Irish or German or whatever, but they were ethnically fully integrated into an entirely different way of life. It is well known that some of those children utterly rejected their “white” historical race when they were “rescued” and offered the opportunity to be “re-integrated”. Some see this as the consequence of a form of “brain-washing”. Others can look at this very differently and see it as a simple consequence of what had become, for those children, a very different “normality”.

    If one thinks that genetics is the only important aspect of a person’s “race”, one is failing to appreciate all of the other factors that are actually key components of the diversity of human life, human behavior, and human health and wellbeing.

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