Active surveillance may be safe for Black men with prostate cancer, study finds

Nov. 3 (UPI) — African-American men on active surveillance for low-risk prostate cancer are more likely than their White counterparts to experience disease progression and ultimately require treatment, a study published Tuesday by JAMA found.

However, men of both races included in the study were at the same risk for metastatic cancer — cancer that has spread to other organs — and death from the disease.

The findings, researchers said, suggest that active surveillance is just as safe for African-American men as it is for White men.

In active surveillance, a person’s cancer is monitored closely, with prostate-specific antigen, or PSA, blood tests taken every six months as well as annual digital rectal exam and prostate biopsies, according to the American Cancer Society.

Based on the results of these more frequent assessments, more aggressive treatment may be recommended, the society said.

“Our research provides evidence that active surveillance is safe for African-American men,” study co-author Dr. Brent Rose said in a press release.

“This means more African-American men can avoid definitive treatment and the associated side effects of urinary incontinence, erectile dysfunction and bowel problems,” said Rose, assistant professor of radiation medicine and applied sciences at University of California San Diego School of Medicine.

Prostate cancer is the second-most common cancer among men, after skin cancer, according to the U.S. Centers for Disease Control and Prevention.

One in nine men will receive a prostate cancer diagnosis in their lifetime, but African-American men are nearly twice as likely to be diagnosed with the disease and more than twice as likely to die from it than men in other ethnic groups, the agency estimates.

The cancer is typically slow growing, and low-risk disease may not need to be treated immediately after diagnosis, if ever, and can instead be monitored under an active surveillance approach, Rose and his colleagues said.

However, because of the increased risk for prostate cancer and death from the disease among African-American men, active surveillance is used less frequently in this population, according to their researchers.

For this study, Rose and colleagues reviewed data on 8,726 men diagnosed with prostate cancer between 2001 and 2015.

About one in four of these study participants were African-American, the researchers said.

Just under 60% of African-American men included in the analysis experienced disease progression, compared to 48% of White men, the data showed.

In addition, 55% of African-American men in the study required treatment compared to just over 41% percent of White men.

Despite these differences, African-American and White men were diagnosed with metastatic prostate cancer at about the same rate — 1% versus 1.4% — and faced the same risk for death — about 1% — as one another.

“Physicians and patients should discuss active surveillance for African-American men with low-risk prostate cancer,” Rose said.

“However, due to the increased risk of progression, African-American men need to be carefully followed and promptly treated if their cancer progresses,” he said.

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Prostate Cancer: Comparing Active Surveillance for Blacks vs Whites

Black men with low-risk prostate cancer undergoing active surveillance had a significantly increased incidence of disease progression and a higher likelihood of needing definitive treatment compared with white men, but did not have an increased incidence of metastasis or prostate-cancer specific mortality, according to a study of men in the Veterans Health Administration (VHA) system.

The retrospective study of 8,726 men in the VHA, including 2,280 Black men, followed for a median 7.6 years showed similar rates of prostate cancer-specific mortality (1.1% vs 1.0%) for Black vs white men despite a more than 10% difference in 10-year cumulative incidence of disease progression (59.9% vs 48.3%; P<0.001) and receipt of definitive treatment (54.8% vs 41.4%; P<0.001), reported Brent S. Rose, MD, of University of California San Diego Health, Moores Cancer Cancer, and colleagues.

In their study, published online in JAMA, active surveillance was defined as no definitive treatment within the first year of diagnosis and undergoing at least one additional surveillance biopsy. The team noted that previous research looking at active surveillance included very few Black men, meaning that the results may not have been generalizable to this patient population.

In the new study, multivariable analysis showed that Black men with prostate cancer were about 30% more likely to have disease progression (subdistribution hazard ratio [SHR] 1.3, 95% CI 1.2-1.4, P<0.001) and receive definitive treatment (SHR 1.3, 95% CI 1.2-1.4, P<0.001) compared with white men.

Despite this increased risk, however, the rates of metastatic disease were similar between the two groups: cumulative incidence at 10 years of 1.5% for Black men and 1.4% for white men.

Additionally, prostate-cancer specific and all-cause mortality rates were similar between the two patient populations, with Black men having no increased risk on multivariable competing risk regression analyses, the researchers reported.

They cautioned, though, that longer-term follow-up is needed to better assess the mortality risk.

“Hopefully, these results encourage African American men with low-risk prostate cancer to consider active surveillance,” Rose told MedPage Today. “Additionally, these findings may support higher rates of PSA screening and early detection if men know that they may not need treatment if they find a low-risk cancer. This will help us to identify the aggressive cancers that do need to be treated in order to reduce the disparity in prostate cancer outcomes for African American men.”

Writing in an accompanying editorial, Xinglei Shen, MD, MS, of the University of Kansas Medical Center in Kansas City, and colleagues acknowledged the dearth of data about whether active surveillance — the use of which is increasing, they note — is as safe for Black prostate cancer patients as it is for white men with the disease.

“This is because prior studies have shown that among Black patients, compared with White patients, the onset of prostate cancer is earlier and tumor volumes are greater even among men with low-risk disease,” the editorialists wrote. “Further, existing data show that Black patients with low-risk prostate cancer who underwent radical prostatectomy were

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Non-Invasive Prostate Cancer Test Boosts Early Treatment

For years, men with an elevated PSA had two options: adopt a wait-and-see approach, or, to find out with certainty whether they had cancer, get a biopsy, a painful procedure where a physician puts a needle through the wall of the rectum and into the prostate. It also carries risk of bleeding or infection.

Instead, Ripken’s urologist, Ronald Tutrone Jr., chief of the Division of Urology at the Greater Baltimore Medical Center, recommended the ExoDx Prostate Test, a newer, simple urine test that looks for genetic changes indicating prostate cancer. When that test came back elevated, Ripken went ahead with a biopsy that indeed revealed he had prostate cancer. He underwent successful surgery in March, and is now in remission.

Ripken feels fortunate his cancer was caught in the early stages, and that he was able to get the ExoDX Prostate Test. “Without it I might have decided to simply watch my PSA levels for a while, and the cancer might have spread.”

For more than thirty years, the PSA has been the gold standard when it comes to detecting prostate cancer. But it’s also had its share of controversy. “There have been concerns that a positive PSA test has led to overdiagnosis and overtreatment,” says James Wysock, M.D., a urologic oncologist and assistant professor of urology at NYU Grossman School of Medicine in New York City. In men with PSA levels in the 4.0 to 10 range, biopsy confirms cancer about 25 percent of the time. This means that the remaining 75 percent would have to undergo a procedure that’s painful, anxiety-producing, and carries risks including infection and bleeding. And even if the test successfully picks up cancer, Wysock adds, many prostate cancers grow so slowly that they will not cause harm during a man’s lifetime. But to be on the safe side, many men opt for treatment, which carries risk of side effects such as incontinence and impotence.

Now, not only can several new blood and urine tests more accurately measure your risk for prostate cancer, they can also detect how aggressive your cancer is, so that both you and your doctor can come up with a targeted treatment. “Not all prostate cancers need to be treated — we can sometimes do what’s known as active surveillance, where you’re monitored over time to see if your levels rise,” explains Wysock.

The ExoDx, which has been available since 2017, works by checking a man’s urine for specific prostate cancer biomarkers that would indicate tumor cell growth. If the test comes back with a score under 15.6, it’s considered low risk or benign. Anything higher could indicate cancer. Ripken’s score was 45.

Similar specific tests to diagnose prostate cancer have been available for close to a decade. Two of the earliest ones were the Prostate Health Index (PHI), FDA approved in 2012, and the 4Kscore test, approved in 2015. These both combine the results of different types of PSA to get an overall score that reflects the chance a man

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More Prostate Cancers Are Being Diagnosed at a Later Stage | Health News

By Steven Reinberg
HealthDay Reporter


FRIDAY, Oct. 16, 2020 (HealthDay News) — While men can take solace in a new government report that shows prostate cancer cases have been declining overall in the past two decades, the same analysis finds that the opposite is true for advanced prostate cancer cases.

In fact, the number of cases of cancer that had already spread from the prostate to other parts of the body doubled between 2003 and 2017, going from 4% to 8%, according to researchers from the U.S. Centers for Disease Control and Prevention.

“Understanding who gets prostate cancer and what the survival numbers are like could be important for men making prostate cancer screening decisions, providers discussing these decisions with their patients, and for informing recommendations for prostate cancer screening,” said lead researcher Dr. David Siegel, from CDC’s Division of Cancer Prevention and Control.

Why the spike in advanced prostate cancers? Dr. Anthony D’Amico, a professor of radiation oncology at Harvard Medical School in Boston, said the increase was an inevitable consequence of a 2012 recommendation from the U.S. Preventive Services Task Force against the routine use of prostate cancer screening with the prostate-specific antigen (PSA) test.

“We realized in 2012, when the U.S. Preventive Services Task Force said to stop PSA screening, we would expect that somewhere around 2018 to 2019 that cancer death rates would start to go up, and that about two to three years prior to that, around 2015 to 2016, we would expect to see distant metastases [cancer that has spread] go up because they preceded death by a couple of years,” he explained.

That’s exactly what this report found, D’Amico noted.

“That trend will continue because the reversal of the recommendation against PSA screening didn’t happen until [2018], so it’s going to be a couple of years from now before we start to see a plateauing and eventually a decrease in distant disease,” he said. “We should have PSA brought back.”

While D’Amico said he believes that men should have their PSA level tested, whether an elevated PSA leads to further diagnosis or treatment should be based on a conversation between a man and his urologist.

“We’re diagnosing less low-risk cases now, but there’s no problem from my perspective in bringing the PSA back, so that the patients with low-risk cancer can have the discussion whether they want treatment or not, knowing what the side effects are, and the patients who need to be cured can be cured,” D’Amico said.

Men are getting more metastatic disease and dying, he said. “But because of the reversal of PSA screening, it should come back to where it was, and the only difference is now we’re smarter about who to treat and who not to treat,” D’Amico said.

The CDC study also delved into racial differences for prostate cancer survival. The researchers found that five-year survival was highest among Asian/Pacific Islanders (42%), followed by Hispanics (37%), American Indian/Alaska Natives (32%), Black men (32%), and white men

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