Prostate Cancer Disparities and the ‘Last Mile’ Problem
William K. Oh, MD
Charles J. Ryan, MD
Prostate cancer is the most commonly diagnosed cancer in men in the United States and the second-leading cause of cancer death.1 It also offers a sobering example in the national conversation on racial disparities in cancer care.
Despite a deeper scientific understanding of the disease—as well as multiple new therapies that improve survival—Black men continue to suffer more than ever from this common disease and its complications. Not only do Black men have the highest rates of prostate cancer diagnosis in the United States, once diagnosed they are more than twice as likely to die of the disease as White men.2 Black men are also more likely to present at younger ages, have a more advanced stage of cancer at diagnosis, and are less likely to participate in clinical trials than White men.
Heading in the Wrong Direction
Unfortunately, recent data show these trends are heading in the wrong direction.3 Following a sharp decline in prostate cancer incidence through 2014, there has been a marked rise in prostate cancer incidence in Black men. Of even greater concern, incidence rates for regional- and distant-stage disease have dramatically increased since that time, with a persistent disparity between Black men and men of other races. This increase coincides with the U.S. Preventive Services Task Force recommendations against prostate-specific antigen (PSA)-based screening for men in 2012.
In our view, as oncologists who treat the disease and fund ground-breaking research at the Prostate Cancer Foundation (PCF), these disparities largely reflect deficiencies in implementation of our best medical practices for screening, diagnosis, and treatment. The gap between established best practices and their delivery is a concept analogous to the supply chain industry’s “last mile problem,” in which the most challenging aspect of delivering a product is the final step into the hands of the consumer. Multiple novel therapies now routinely prescribed in the clinic can trace their roots to PCF-led science and discovery. But is it enough?
Turning the Tide on Disparities in Prostate Cancer
Here are three areas where we need continued investment to turn the tide on prostate cancer disparities:
• Research: We believe that when nonprofits, industry and government work together, we can achieve more than the sum of our individual parts. For instance, in partnering with the Department of Veterans Affairs (VA), the PCF built a network of Prostate Cancer Centers of Excellence for genomic testing and clinical trials.4 The VA is already one of the most equal-access health-care systems in the world; PCF and the VA used philanthropy to spearhead broader genomic testing and increased clinical trial availability in advanced prostate cancer, accelerating new treatments in the clinic for all. In fact, survival rates for advanced prostate cancer are equal in the VA between Black and White men.5
“Despite a deeper scientific understanding of prostate cancer..., Black men continue to suffer more than ever from this common disease and its complications.”— —WILLIAM K. OH, MD, AND CHARLES J. RYAN, MD
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• Screening: Prostate cancer is curable with earlier detection. However, not all prostate cancers are dangerous, and overtreatment of some slow-growing cancers may lead to side effects without benefit if screening is not individualized. Since Black men face higher rates of advanced cancer at younger ages, early detection in this group will have an outsized benefit compared with the overall population.6 Thus, despite a long-standing debate on the value of prostate cancer screening for all populations, we believe that screening in most Black men should be considered as a standard of care. Effectively delivering this message to Black men and their families should be a priority.
• Awareness and Education: Solving the last mile problem requires community: patients, families, local leaders, health-care providers, and professional medical societies. Awareness begins with understanding one’s individual risk but also knowing one’s family history. Awareness demystifies: Consider the confidence that one can take in knowing that (1) not all prostate cancer requires treatment; (2) that side effects are greatly reduced with new treatment advances; and (3) screening may no longer require the digital rectal exam, a fact that may help drive up the numbers of men screened.7
So, what next? We believe a series of focused steps will help to deliver better prostate cancer care to Black men in the United States. First, the Prostate Cancer Foundation has convened the first-ever guidelines panel for prostate cancer screening and treatment specifically focused on recommendations for Black men. Our goal is clarity. Second, we call for a standing committee for prostate cancer implementation organized at the federal level, with representation by community leaders, foundations, government agencies, industry, and professional societies.
Finally, we urge an increase in funding for implementation science through awards programs in communities of color, focused on awareness, screening, and education. The cost of care for metastatic prostate cancer is estimated at more than $8 billion annually,8 at least three times higher than if the cancer is identified at an earlier stage. Creating a common database of clinical outcomes to track real-world evidence and to increase grassroots efforts in communities to address screening and treatment would be well worth the investment.
As the COVID-19 pandemic has shown, medical progress is often distributed unequally across populations. To deliver optimal prostate cancer care for all, it is imperative that we understand and overcome implementation barriers for Black men. By ensuring that our scientific progress and treatments reach every patient in the United States, we together will overcome the last mile problem.
DISCLOSURE: Dr. Oh has served as a consultant to Pfizer and holds stock in GeneDx. Dr. Ryan reported no conflicts of interest.
1. Siegel RL, Miller KD, Wagle NS, et al: Cancer statistics, 2023. CA Cancer J Clin 73:17-48, 2023.
2. Lillard JW Jr, Moses KA, Mahal BA, et al: Racial disparities in Black men with prostate cancer: A literature review. Cancer 128:3787-3795, 2022.
3. Schafer EJ, Jemal A, Wiese D, et al: Disparities and trends in genitourinary cancer incidence and mortality in the USA. Eur Urol. December 21, 2022 (early release online).
4. Levine RD, Ekanayake RN, Martin AC, et al: Prostate Cancer Foundation–Department of Veterans Affairs partnership: A model of public-private collaboration to advance treatment and care of invasive cancers. Fed Pract 37(suppl 4):S32-S37, 2020.
5. Klebaner D, Courtney PT, Garraway IP, et al: Association of health-care system with prostate cancer–specific mortality in African American and non-Hispanic White men. J Natl Cancer Inst 113:1343-1351, 2021.
6. Nyame YA, Gulati R, Heijnsdijk EAM, et al: The impact of intensifying prostate cancer screening in Black men: A model-based analysis. J Natl Cancer Inst 113:1336-1342, 2021.
7. Krilaviciute A, Lakes J, Radtke JP, et al: Digital rectal examination is not useful as a solitary screening tool for prostate cancer in young men—Results from the PROBASE trial. 38th Annual EAU Congress. July 4, 2022. Abstract A0899.
8. Olsen TA, Filson CP, Richards TB, et al: The cost of metastatic prostate cancer in the United States. Urol Pract 10:41-47, 2023.
Dr. Oh is Chief Medical Officer of the Prostate Cancer Foundation and Clinical Professor of Medicine at Icahn School of Medicine at Mount Sinai. Dr. Ryan is Chief Executive Officer of the Prostate Cancer Foundation.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.