Eradicating Racial Differences in Prostate Cancer Outcomes

Dedicated in loving memory of Calvin Harris Snr

A report written as part of my Masters of Communication Data Science at University of Southern California in Fall 2018.

Abstract

Racial disparities in health care outcomes contribute to African Americans (AA) men living ten years less on average than a white American (Rosenberg, Ranapurwala, Townes, & Bengtson, 2017).  One of those disparities is due to prostate cancer (PC), the second most deadly form of cancer in America, with a mortality rate double the rate for AA men than non-Hispanic whites (American Cancer Society, 2018).  This literature review examines the research for possibilities to reduce this racial disparity to zero, by asking what are the underlying factors that cause these outcomes for AA men?  This question will be answered by considering the attitudes, beliefs and behaviors of both patients and health care providers and focusing on where there are racial differences.

Keywords:  Prostate Cancer, Racial Disparity, African American, Reasoned Action Approach

Eradicating Racial Differences in Prostate Cancer Outcomes
Literature Review

Racial disparities in health care outcomes contribute to African Americans (AA) men living ten years less on average than a white American (Rosenberg et al., 2017).  One of those disparities is due to prostate cancer (PC), the second most deadly form of cancer in America, with a mortality rate double the rate for AA men than non-Hispanic whites (American Cancer Society, 2018).  This literature review examines the research for possibilities to reduce this racial disparity to zero.

Prostate Cancer in America

In 2018, 29,000 American men are predicted to die due to PC, and160,000 new cases will be diagnosed (American Cancer Society, 2018)1. 

The longer a man lives, the higher the likelihood he will have PC, yet most men “die with prostate cancer, not die from it” (Ablin, 2014; Peehl, 1999).

This is because the unique, dual nature of PC: one type is microscopic, almost latent and very slow growing, and the other is much more aggressive, metastic and deadly (Ablin, 2014; Peehl, 1999; Schröder, Hugosson, Roobol, & et al, n.d.) 2. Therefore, despite PC being so fatal, the numbers are relatively low considering how many will men have it (Peehl, 1999).

Incidents and deaths from PC skyrocketed in the nineties (National Cancer Institute, 2017). At this time, a general male population test was introduced; the prostate specific antigen (PSA) test, but its use quickly became controversial (Ablin, 2014).

It is not cancer-specific, and as there is a high incidence of pre-malignant microscopic lesions in most prostate glands, critics argue the test overdiagnoses the severity of the cancer, resulting in unnecessary biopsies and radical treatment, rather than watching and waiting to determine what kind of tumor it is 3  (Ablin, 2014; Andriole et al., 2009; Benoit & Naslund, 1995; Halpern et al., 2017; Lyons et al., 2017; Moyer, 2012; Peehl, 1999; Schröder et al., n.d.; Vollmer, 2012).

In fact, in 2012 the U.S Preventive Services Task Force (USPSTF) recommended against the use of PSA for general population screening, but rather recommended it for use in Active Surveillance to determine the rate of growth of the cancer (Andriole et al., 2009; Moyer, 2012).

The changing levels of use of the PSA test before and after the USPSTF recommendation has directly and significantly impacted the biopsy and radical prostatectomy volumes (Ablin, 2014; Halpern et al., 2017).

This conflict between health care practice and the advice of government bodies makes a challenging environment for the prevention and treatment of PC.

Prevalence of Prostate Cancer in African American men

Disturbingly, African Americans (AA) have for many years had the highest rates of PC caused fatalities in the world (Blocker, Romocki, Thomas, Jones, & al, 2006; Levi, Kohler, Grimley, & Anderson-Lewis, 2007; Odedina, Scrivens, Emanuel, LaRose-Pierre, & al, 2004).

In 2017, prostate cancer incidence rates for African Americans (AA) were 1.5 times more likely than for non-Hispanic white Americans  (NHWs), and mortality rates were double that of NHWs (National Cancer Institute, 2017; Taksler, Cutler, Giovannucci, Smith, & Keating, 2013; Taksler, Keating, & Cutler, 2012).

The AA mortality rate has dropped by over 30% since 2007, and over 400% since 1993, when the disparity was 2.5 times greater likelihood to die from prostate cancer than NPW,  however this is still a very poor outcome for a lot of Americans (National Cancer Institute, 2017; Taksler et al., 2012).

The direct drivers of this disparity are threefold: AA develop PC earlier in life, and the cancer is at a later stage when diagnosed, and once diagnosed AA do not receive all the recommended treatments (American Cancer Society, 2018; Hawley & Morris, 2017; Levi et al., 2007; Morris, Rhoads, Stain, & Birkmeyer, 2010; National Cancer Institute, 2017).  

This literature review asks: what are the underlying factors that cause these outcomes for AA men?  

From a biological point of view, there is no strong evidence to date to prove that AA experience more aggressive tumor biology than NDWs (Jaratlerdsiri et al., 2018; Morris et al., 2010). African genes may be more susceptible to PC in general however,  (Chornokur et al., 2012; Wang et al., 2017), and  recent genome sequencing research has indicated the potential for a genetic difference resulting in worse health outcomes for those with African genes (Jaratlerdsiri et al., 2018).

Physically, the reduced ability to absorb vitamin D may be contributing to racial disparities. Vitamin D deficiency has been linked to prostate cancer, and AAs with higher melanin in their skin are slower to absorb Vitamin D than white people (Peehl, 1999; Taksler et al., 2012). Further research in the biology of PC in AA would be worthwhile.

Lower socioeconomic status (SES) is a factor in lower PC survival rates (Klein & von dem Knesebeck, 2015), and as a large proportion of AA are in lower SES groups than NHWs, they suffer PC disproportionately due to SES also  (Morris et al., 2010).

The rest of this literature review focuses on whether there are racial disparities in patient and practitioner behavior that may contribute to AA to not be diagnosed early enough and to not receive all the recommended treatment (Morris et al., 2010).

Exploration of casual factors in racial disparity using Reasoned Action Approach

 The reasoned-action approach can be used as a framework to predict a person’s behavior towards prevention, screening and treatment of PC (Ajzen, 1991; McEachan et al., 2016; Tippey, 2012).

“The reasoned-action approach states that attitudes towards the behavior, perceived norms, and perceived behavioral control determine people’s intentions, while people’s intentions predict their behaviors.” (Levi et al., 2007).

Patient Attitudes, Beliefs and Perceptions  

Patients behaviors regarding prevention, screening and treatment options have many influences, some have been proven to contribute to racial disparities in PC outcomes, and others have not.

Participation in prevention and screening behavior

In terms of preventative health attitudes and behaviors, research has found that a diet high in red meat and fat increases the risk of prostate cancer, and conversely a diet high in vegetables (especially cruciferous vegetables) has been shown to reduce it  (Blocker et al., 2006; Cohen, Kristal, & Stanford, 2000).  The AA diet is generally worse on these measures than white men (Blocker et al., 2006). Attitudes underlying this difference could be a significant contributor to the racial disparity in mortality rate and would be good to research further.

AA have lower participation rates in PC screening that NHW (Morris et al., 2010), which definitely contributes to the higher mortality rate. There are different reasons for this.

Research has found that those with family history have greater knowledge of the risk of PC as representativeness and availability heuristics works towards weighting the risk appropriately (McDowell, Occhipinti, & Chambers, 2013). There is no evidence that this is a cause of racial disparity however.

However, there is a body of research supporting significant negative associations to screening behavior in AA men, relating to feelings of embarrassment, decision regret for multiple types of treatment and threats to masculine sexual identity as a result of impotence and lethargy following treatment, but again it is not known if these contribute to the racial disparity (Allen, Kennedy, Wilson-Glover, & Gilligan, 2007; Collingwood et al., 2014; Hawley & Morris, 2017; Odedina et al., 2004).

Studies have shown that awareness or knowledge of screening was less of an indicator of participating in screening than being advised to do so by a doctor (Meissner, Potosky, & Convissor, 1992). Evidence supports that there is a racial discrepancy in having a regular doctor, and trust in the health care profession, due to a history and perceptions of racism, and also cognitive biases and difficulty in communication because so many of the medical profession are white and have different cultural sensitivities (Blocker et al., 2006; Hawley & Morris, 2017; Kahneman & Frederick, 2002; Morris et al., 2010; Odedina et al., 2004). 

Building up trust and regular contact with the medical profession is vital for AA to receive culturally and personally relevant advice, to encourage participation in screening despite the negative associations and attitudes towards prostate cancer (Grubbs et al., 2013; Hawley & Morris, 2017; Morris et al., 2010).  A program in Delaware brought the racial disparity in colorectal cancer down to zero over ten years, through building up trust by using local doctors and community leaders to promote screening behaviors (Grubbs et al., 2013).

Attitudes and preferences in regards treatment

Attitudes and preferences towards treatment options have been measured in studies in terms of expectations, decision conflict, satisfaction and regret, and mostly there were no racial disparities, except for one very important one (Collingwood et al., 2014; Lyons et al., 2017; Meissner et al., 1992; Potosky et al., 2001; Reamer, Yang, & Xu, 2016).

The main racial disparity lies in the lower proportion of AA men who participate in a shared decision-making process with their doctor, which in turn affects the metrics (Collingwood et al., 2014; Hawley & Morris, 2017; Morris et al., 2010).  

One study found that decision regret was greater in African Americans, for both radical surgery and non-treatment, and it was suggested that this could be due to the level of shared decision making with the health care provider to manage patient expectations (Collingwood et al., 2014).

Higher decision regret due to reduced quality of life from radical surgery can reinforce the community’s negative associations with prostate cancer, and influence the number of people participating in screening (Blocker et al., 2006; Hawley & Morris, 2017)

In addition, if the treatment is biased towards active treatment over active surveillance, these impacts can also be totally avoidable because the surgery may be unnecessary, and therefore these outcomes reinforce the feeling of mistrust (Ablin, 2014; Reamer et al., 2016; Xu et al., 2016).    

Studies have shown there does tend to be a bias towards active treatment over active surveillance, however no racial differences were found in the results (Reamer et al., 2016; Xu et al., 2016). Patients are fearful upon being diagnosed with PC, and feel that active surveillance is “doing nothing” (Reamer et al., 2016; Xu et al., 2016). Hence doctors play a vital role in ensuring patients control their fear and make a good decision for their treatment (Blocker et al., 2006; Reamer et al., 2016; Xu et al., 2016).

Lyons et al also looked at preferences for active treatment (AT) versus active surveillance, and found that people with a close relationship with a trusted physician were able to overcome their preference for AT (Lyons et al., 2017). Again, no racial disparity was found, but this must be considered in the context of lesser participation of regular contact with a regular doctor in AA communities (Grubbs et al., 2013; Hawley & Morris, 2017; Morris et al., 2010).

Health Care Providers Knowledge and Beliefs

The literature reveals three potential factors for unbalanced representation of AA in PC health care.

Researchers

Researchers may be employing heuristics that unintentionally create systematic bias that excludes AA in their research, or focus overly on them as controlling the outcome (Kahneman & Frederick, 2002).

For example, Vastola et al argue that the criteria for participation in clinical trials are set at levels that exclude a disproportionate number of AA, due to differences in the average levels for these criteria between NHW and AA populations (Vastola et al., 2018).

Whilst there has not been a review of research disparities in PC, research conducted by Rosenberg et al found that homicide was the biggest contributor to mortality for AA and received significantly less research funding and effort than heart disease which was the greatest killer of white people (Rosenberg et al., 2017).

Therefore, researchers need to consider if their programs are unintentionally excluding African Americans.

Health Care Providers

Health care providers are essential to giving AA patients sound advice when choosing active treatment over active surveillance, given the consequences to the patients quality of life (Ablin, 2014; Collingwood et al., 2014; Lyons et al., 2017). Patients are biased towards action due to the fear of being diagnosed with PC, and feel that active surveillance is doing nothing (Ablin, 2014; Collingwood et al., 2014; Lyons et al., 2017). It is up to the doctor to advise them that most PC is not aggressive and should be monitored in the first instance, because once they are referred to a urologist, the chance of them having surgery increases dramatically (Ablin, 2014; Collingwood et al., 2014; Lyons et al., 2017).

Administrators and Government

There is a very sound business case for government investment in free screening and treatment of PC for lower SES African Americans.

A ten-year trial in Delaware for colorectal cancer reduced the racial disparity in mortality to zero by providing free screening and treatment to low SES people, and it was much cheaper than funding surgery and medicines (Grubbs et al., 2013). This program was also culturally sensitive, utilizing local doctors and community leaders like pastors to promote screening (Grubbs et al., 2013).

Government and policy makers must consider if they are biased towards cures rather than prevention, or are allocating resources towards one community over another and contributing to the PC mortality rate disparity.

Further areas for research

Overall, it is difficult to grasp which factors are the more significant contributors to racial disparity in PC mortality from the research, because each study is on such a narrow topic.

Therefore, further research to measure the impact of each factor would be useful to be able to prioritize efforts to reduce the AA mortality rate.

An analysis of the research from this perspective, plus quantitative analysis to build a predictive model would be useful.

Also, researchers should try to cover the views of patients and practitioners in their studies, as that relationship is so important in the prevention of PC deaths.

Lastly, research into the reasoned action approach in relation to a PC preventative diet would also be fruitful.

References

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Footnotes

1 For the record, lung cancer is the greatest killer for both men and women, with over 150,000 deaths estimated for 2018 (American Cancer Society, 2018).

2 “Independent, multiple foci of cancer are present in the majority of prostate specimens, and the incidence of premalignant lesions is even higher than that of cancer. Yet, despite the high incidence of microscopic cancer, only 8% of men in the US present with clinically significant disease during their lifetime. Furthermore, only 3% of men in the US die of prostate cancer. In no other human cancer is there such disparity between the high incidence of microscopic malignancy and the relatively low death rate. Thus, there are many windows of opportunity for control of prostate cancer.” (Peehl, 1999)

3 There are a number of different treatment options for PC: open retropubic radical prostatectomy, the newer robot assisted laparoscopic prostatectomy, external beam radiation, primary androgen deprivation therapy (to castration levels) and active monitoring/surveillance (Collingwood et al., 2014; Potosky et al., 2001; Segal et al., 2003).

Figure 1 Conceptual Model

Figure 1.  A conceptual model of mechanisms underlying disparities in cancer outcomes  (Morris et al., 2010)

As shown in Figure 1 above, cancer outcomes are influenced by effective cancer care, which in turn is driven by the patient’s utilization of health care, and quality of health care provided by the system and practitioners (Morris et al., 2010).  

Utilization of health care can be influenced by the patients socioeconomic status (SES) which affects their knowledge and ability to pay for care, geography which affects their access to care, race as physical differences can make a person more susceptible to certain cancers, and the persons beliefs and preferences (Morris et al., 2010).   There are also physical differences such as cancer stage, tumor biology, and comorbid diseases.

The quality of health care is influenced by the practioners knowledge, beliefs and technical skills, and the resources of the health care system (Morris et al., 2010).  

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