In this MD Newsline exclusive interview with urologist Dr. Fenwa Milhouse, we discuss how prostate cancer disparities affect Black and Brown communities.
Why do Black and Brown communities suffer more from prostate cancer?
Dr. Fenwa Milhouse:
“We know that Black men consistently have higher rates of prostate cancer occurrence and prostate cancer death. Even in the lowest-risk category, Grade 1 or Gleason 6 low-risk prostate cancer, Black men have the highest risk of death. The disparity in prostate cancer death is highest in the lowest-risk prostate cancer. Ok?
Again, I want to be clear. The disparity of prostate cancer death is highest among the lowest-risk or the least aggressive prostate cancer. Black men are less likely to receive definitive therapy or treatment for prostate cancer. Ok? They’re less likely to receive the most appropriately complete surgery if they undergo surgery for prostate cancer.
What does that mean? They’re less likely to receive a pelvic lymph node dissection, where we take some of the pelvic lymph nodes—which is a standard practice in prostate cancer surgery—they’re less likely to undergo that practice for prostate cancer surgery.
So much research has been done to find out if there are genetic or biologic factors involved. Quite frankly, we really have not found any conclusive differences to account for these disparities. And what we do know is this disparity is probably treatable. It’s likely non-biologic, preventable factors that play the greatest role in the disparity.
And let’s think about it. Black patients have the highest risk of death. We’ve known this [fact] for decades. But yet they are the least likely to receive definitive and appropriate therapy. How is that possible? What are we doing? Our highest-risk patients are getting the poorest treatment.
According to the U.S. Department of Health and Human Services, we know that Black and Latino patients receive worse care on 40% of the department’s care quality measures. So we need to stop saying that race is a risk factor and start acknowledging that racism is a risk factor. Racism is akin to social and economic factors, and they play a significant role in health disparities overall.”
How does socioeconomic status impact prostate cancer management?
Dr. Fenwa Milhouse:
“Socioeconomic status is everything. Public health has called this concept social determinants of health, which account for most healthcare disparities overall, including prostate cancer disparities. Social determinants of health are those conditions that we are born into and live and grow in. They are our communities, our education, our employment, our income, our social support, our community resources, and our safety, for example.
These social determinants or socioeconomic factors determine our risk of exposure [to disease] and our access to resources to help with our medical conditions. They influence the access and quality of medical care that we receive. And social determinants of health are absolutely shaped by the distribution of wealth and influence in our society. They’re shaped by programs and policies that have been in place for eons and eons. Ok?
Where does the money go? How are resources distributed? And, guess what? That brings it all back to structural racism, compounded and chronic inequities that still exist and persist in society. Even if legally policies say you can’t discriminate based on race, there are inherent practices that are discriminatory or inequitable based on race.
And so that trickles down into our social determinants of health, where communities are invested in or divested. Ok? If my community is thought to be a poor investment, then we aren’t gonna have public works and fiscal education. We’re not gonna have good nutritious [food] sources. I’m gonna be in a food desert.
Studies have shown that Black and Brown communities have a lower proportion of nutritious foods and playgrounds, a higher risk of exposure to environmental toxins—almost 1.5 times more so than predominantly white communities—have a greater density of liquor and tobacco stores, and less access to medicine. Alright?
I love this quote by Dr. Damon Tweedy, author of Black Man in a White Coat. He says being Black is bad for your health. And what he’s basically saying is that structural racism affects our access and exposure, our housing, our education, nutrition, all of those things that I’ve just listed and given examples of, and that absolutely affect our risk of disease.”
How might we improve messaging surrounding prostate cancer screening, particularly for minority groups?
Dr. Fenwa Milhouse:
“We have to meet patients where they are. Why are they not getting screening? Let’s figure that out. I think there is some stigma about the prostate exam or prostate cancer screening in general. It’s been made into this horrendous thing that men might have to endure. And I think we have to destigmatize screening and ease patients’ fears about it and truly meet them where they are.
So let’s say I have a patient who does not want a rectal exam. Well, ok, I’ll do a blood test to screen you. We have to meet people where they are. If we don’t do that and just give all-or-nothing screening, then we’re going to miss a lot of patients that we can screen just as well.
We have to normalize in our communities going to the doctor regularly, whether you feel bad or not. I have some patients who haven’t been to the doctor in years tell me, ‘well, I haven’t felt bad. I feel fine.’ And I’m telling them, ‘you know you have to get a checkup before you feel bad. You don’t want your prostate cancer to make you feel bad before you realize, oh, I should’ve gotten it checked out because then it’s way too late.’ And that’s the case with a lot of diseases.
And so, we have to speak on that in our communities. And not just coming from health professionals, but professionals of all walks [of life]. Let’s talk about it in our churches. Let’s talk about it in our community centers. Let’s talk about it at City Hall. And teach our communities to be advocates for their own health. I think a lot of patients, in general, need to be encouraged to speak up, ask questions, and develop this advocacy so that they know they are getting treated appropriately.”
Responses have been condensed and lightly edited.