Integrating Racial, Metabolic and Neighborhood Factors Associated with Prostate Cancer Progression and Outcome
Prostate cancer incidence and mortality have consistently been higher in Black men than White men. Recent statistics from U.S. Surveillance, Epidemiology and End Results registry data show that Black men have a 66 percent higher incidence and twice the death rate than white men. This pattern was observed well before 1990, when the era of aggressive screening and treatment of localized disease began. The racial disparity in prostate cancer outcomes between men of African descent and men of European descent is among the most severe across cancer types and has been extensively studied. However, the mechanisms that explain this disparity are complex, including social and biological factors that remain poorly understood. Furthermore, the standard of care in prostate medical oncology and related specialties has been built largely on data derived from analyses of men of European descent; therefore, prediction models do not fully capture the range of racial diversity.
Although prostate cancer-specific survival rates differ by race, some of the difference might be explained because Black men tend to be diagnosed at more advanced stages. Dr. Otis Brawley, a clinician and thought-leader at Johns Hopkins University, has noted that when men treated in equal access systems, such as through Veterans Affairs hospitals, or in clinical trials with both access and standardized treatment, Black men have similar or potentially improved prostate cancer outcomes compared to white men, when clinical factors are similar [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8763361/]. Considering these associations, steps are being taken to maximize community engagement, patient outreach and navigation, and culturally sensitive care for underserved patients at every point of contact with the hospital system, from the first visit to urology, through to imaging, surgery or radiation, medical treatment and survivorship support.
U.S. safety net hospitals like Boston University/Boston Medical Center, which treat a disproportionately large fraction of Black men compared to other centers, have a high prevalence of obesity and Type 2 diabetes. Our research teams have shown that metabolic co-morbidities shorten the time to biochemical progression of prostate cancer and associate with worse outcomes, yet ‘metabolic disparities’ rarely inform risk assessment. These insights are prompting us to more deeply investigate the circumstances under which our patients live and the social determinants of health that they face daily. Our survey of Clinical Data Warehouse information indicates that patients with Type 2 diabetes live in zip codes that are food, transportation and housing ‘deserts.’ This triumvirate of health access barriers limit the ability to interact with our patients on a regular basis.
Taken together, we have convincing reasons to engage our patients about their diets, exercise, access, navigation through the hospital system, and to increase follow up visits and health monitoring to improve outcomes. Integrating these diverse factors into a coherent plan to engage patients and optimize treatment is a feature of our clinical and research effort, setting us apart from the neighboring health systems in greater Boston.