Prostate Cancer: The Disparate Burden of the Disease Among Black Men

Lorelei Mucci
William Dahut
American Cancer Society

he burden of prostate cancer is considerable and growing. In 2020, 1.4 million incident prostate cancers were diagnosed and 375,000 prostate cancer deaths occurred globally. By 2040, the numbers will grow to 2.4 million incident prostate cancers and an almost doubling of prostate cancer deaths per year.

Prostate is also the cancer with the largest racial disparities, with the greatest public health impact among Black men. Racial disparities are evident at every stage of the prostate cancer continuum, including an excess cancer incidence, a higher rate of diagnoses of advanced-stage tumors, increased prevalence of metastatic prostate cancer survivors, and an excess prostate cancer mortality. This article discusses prostate cancer racial disparities in the United States and across the globe, and provides a call to action to reduce and eliminate these disparities in order to improve prostate cancer outcomes for all.

Burden of Prostate Cancer Among Black Men in the United States

288,300 men will be diagnosed with prostate cancer in 2023, 16% of whom will be Black men, translating to an age-standardized incidence that is 1.7 times higher than among White men. For mortality, the disparity is even larger. An estimated 18% of the 34,700 prostate cancer deaths in the United States each year occur among Black men, resulting in a 2.1 times greater age-standardized prostate cancer mortality. If Black and White men with prostate cancer had similar case fatality, one would expect a population mortality rate closer to 1.7, matching the difference in incidence. However, in the real-world setting, Black men are more likely to be diagnosed with advanced prostate cancer, receive less guideline-concordant treatment, and have less access to care.

Two concerning patterns have emerged in recent descriptive statistics for prostate cancer in the United States: a slowing of progress in reductions of prostate cancer mortality for all patients and an increased incidence of cancers diagnosed at an advanced stage. These trends will likely offset the notable reductions in prostate cancer mortality in the United States over the past 15 years as well as exacerbate racial disparities.

Metastatic Prostate Cancer Patients and Lack of Diversity in Clinical Trials

Another area of racial disparities is among patients with advanced prostate cancer. Almost all prostate cancer deaths occur in patients whose cancers have progressed to metastatic castration-resistant prostate cancer (CRPC). These patients are not only at greater risk of death, but also experience worse quality of life, due to the severity of the cancer as well as its treatments. An estimated 120,400 patients were living with metastatic prostate cancer in 2018, of whom 22,000 (18%) were Black. The number of metastatic prostate cancer survivors is expected to rise to 190,000 by 2030, and Black men will remain overrepresented in this patient population.

Despite a larger burden of prostate cancer incidence and mortality, Black patients are under-represented in clinical trials. A review of Phase III and IV prevention, screening, and treatment clinical trials in prostate cancer included 893,378 individual trial participants in 72 trials. In the 59 (82%) of trials with available race data, the percentage of Black participants ranged from 0.5% for screening trials and 6.7% for treatment trials. In communications with authors of trials where race was not reported, the authors reported that 100% of the patients on those trials were White.

While prostate cancer mortality rates are greater among Black vs. White men, there is intriguing evidence that Black men with advanced prostate cancer on clinical trials may do as well, and potentially better, than White men in some clinical settings. In a reanalysis of 8,820 CRPC patients from nine trials of docetaxel, 6% of patients were Black. Black patients had worse performance status and higher PSA at enrollment. While median overall survival was similar in Black vs. White men, there was a 19% lower risk of death among Black patients after adjusting for prognostic factors.

The interpretation of this study is that overall survival would be better among Black patients if they had the same prognostic factors at enrollment (which they did not). ABI-Race is one of the first prospective studies to enrich for Black patients, enrolling 50 Black and 50 White CRPC patients on abiraterone plus prednisone. Despite greater comorbidities in Black patients at enrollment, they had similar overall survival and radiographic-free progression compared to White patients, and a tendency toward greater PSA declines.

Burden of Prostate Cancer in Black Men Globally

The exact number of Black men affected by prostate cancer globally is unknown given the lack of race-specific cancer statistics across the majority of countries. However, regions with the highest prostate cancer mortality rates include those in the Caribbean, sub-Saharan Africa, and parts of South America. As a corollary, prostate cancer survival after diagnosis is strongly linked to the Human Development Index, with countries with lower indices having worse prostate cancer-specific survival. Despite this higher burden, there is a dearth of prostate cancer research within these geographic regions.

A Call to Action

There is an urgent public health and clinical need to prevent prostate cancer mortality among all men, stop the incidence of cancers at an advanced stage of diagnosis, and eliminate the considerable disparity in Black men. Meeting these public health goals will require the implementation of a multipronged strategy in at least four important focus areas:

The implementation of strategies targeted to primary prevention of prostate cancers that ultimately would become fatal: there is strong scientific evidence to support the benefits of factors such as regular physical activity, healthy body weight, not smoking, and healthy dietary patterns in reducing the risk of aggressive and fatal forms of prostate cancer. Such interventions may also improve quality of life and cardiometabolic health, and prevent chronic diseases in prostate cancer patients. Part of racial differences in prostate cancer may indeed be due to barriers to healthy lifestyle.
Increasing screening and earlier detection of prostate cancers when cure is still possible: randomized trials have shown the benefit of PSA screening on reducing prostate cancer mortality. There is intriguing evidence that integration of PSA together with additional approaches could be useful to risk-stratify patients and target regular screening for those at highest risk of fatal prostate cancer, reducing screening for low-risk individuals to avoid overdiagnosis of pseudo-disease.
Ensure equal access to care and treatment including among all patients: this is perhaps one of the more challenging elements, given the healthcare structure in the United States, as well as inequities, structural biases and racism, and financial barriers. There is an even greater lack of access and affordability to the newer FDA-approved prostate cancer therapies in many of the low- and middle-income countries with the highest prostate cancer mortality rates.
Increase diversity in prostate cancer clinical trials: this is an essential element to accelerate the benefits of novel therapies for all patients, and to quantify the benefits and harms as well as impact on quality of life in diverse populations. Enhancing diversity includes not only increasing representation of Black men but also participation from regions of the world under-represented in oncology trials. To accomplish this, there is a need for enhanced clinical research infrastructure across US centers, greater partnerships between US NCI-funded cancer centers with community oncology practices to ensure greater access to trials, as well as enhanced partnerships between academic, foundations, and pharma partners to make this a priority. Both within the US (community practices) as well as globally, there is a need to enhance clinical trial research infrastructure to successfully conduct such trials.

References available upon request.

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