MD Newsline recently interviewed urologist and Cofounder of MedAux Dr. Behzad Jazayeri about PSA testing and prostate cancer health disparities in Black men.
MD Newsline: Dr. Jazayeri, several studies have found that prostate cancer is more common amongst black men. What makes them much more susceptible?
Dr. Jazayeri: This is a question that we have been trying to answer for the past 20 years. Initially, we linked all these differences between the diagnosis of the cancer to socioeconomic status or as we call it now, social determinants of health. These social determinants of health are very important in our health system as a general fact. But what we know right now is that prostate cancer in different races acts very differently. We know from a biologic standpoint that we are becoming aware that prostate cancer in African Americans and people of African descent is more aggressive than Caucasians in general.
It’s very interesting to see new treatment modalities, like immunotherapy, which is very dependent on the biology of the cancer and the genetic background of the person. We see that people of different ethnicities and different races respond very differently to these immunotherapy medications. It’s a complex issue because, it’s not just one factor, it’s multifactorial, and that can include: social determinants of health, access to healthcare, maybe culture or background and also the biology of the disease itself. So, there is a lot of research ongoing right now to find out exactly in which generative backgrounds there are genes that are diagnosed in prostate cancer that are specifically concerning African American men. It’s an ongoing process and we are still working and learning new things every day.
MD Newsline: Dr. Jazayeri, are there other groups that are at high risk of developing prostate cancer as well?
Dr. Jazayeri: So, if a man is diagnosed with prostate cancer, in order to offer them treatment, we classify them into low risk, intermediate risk and high-risk groups. Therefore, high risk prostate cancer depends on the biology of the cancer itself. If the cancer is aggressive, we see that it’s more likely to spread through the body. Then we have lab data that we look at it to see if that person is high risk, and that’s a separate high-risk group.
There are different societies that have different opinions on this, but as a general rule, African American men are put are at higher risk of having prostate cancers in their lifetime than the general population. Prostate cancer is approximately 30% to 40% more common in African American men. We say one out of six African American men will be diagnosed with prostate cancer as compared to one out of eight Caucasian men. This is a very high number. We should also have it in context that prostate cancer is the most common cancer, and it’s the leading cause of death in men from cancer. So, it’s a common disease and it’s a lethal disease at the same time.
MD Newsline: Concerning PSA testing guidelines, do you feel that the guidelines are clear and that most physicians are knowledgeable about how to test and when to test?
Dr. Jazayeri: This is also an area that there is a lot of debate. PSA testing was introduced in 1980s and 1990s. It’s a very simple process and everyone can do it in five minutes. Even at the beginning, it was a very simple test, but what happened as the testing became widespread during those 1980s and 1990s, more and more men were diagnosed with prostate cancer. So, the incidents or the number of men diagnosed with prostate cancers went very high and there was a peak. The problem is that prostate cancer is a very heterogeneous disease, meaning that there are types of prostate cancer that will not kill you. So even if a man has a very low risk prostate cancer, although we are aware that there is cancerous tissue in the prostate, we don’t need to treat them, and this is a new concept.
This concept emerged after following patients with prostate cancer for 30 years and watching and seeing that these types of prostate cancer, which we call low risk, prostate cancer, or very low risk prostate cancer don’t need to be treated. We can just observe the patients. After this data started to come in front of us, the societies, tried to answer this question; is it cost-effective to do PSA testing? And by doing PSA testing and treating the cancer, are we doing more harm to the patients? So, there begins the complexity of a PSA test. To put it in context, PSA testing is a very sensitive test, meaning that even if you have the lowest risk of prostate cancer, if you’re diagnosed, the problem is we cannot differentiate the very low risk to the very high risk just based on the PSA.
When you do PSA testing and there’s an abnormal value, you have to dig further to see if it is a hydrous cancer or lower risk and determine what to do for treatment. The digging though, has cost implications and risks for the patient as well, because then you need to perform a prostate biopsy and a prostate MRI. This is one of the reasons that a US task force, a couple of years ago, recommended against screening for prostate cancer with PSA. Therefore, many physicians have stopped offering PSA testing to men. This way the incidence of patients that have prostate cancer goes down because we are not diagnosing. At the same time, the men with prostate cancer that presented metastasis, meaning when the cancer is outside of the prostate, we can’t do anything for because we delayed the time of diagnosis by not doing a screening.
MD Newsline: What recommendation would you make to physicians treating patients in the high-risk age group?
Dr. Jazayeri: The recommendation is to make it a shared decision-making model with the patient. This means that when the patient comes into the clinic we need to talk about prostate cancer with the patient. The recommended age is about 50, and that that point we should offer patients the PSA testing. We can do it. We might get a high number but that doesn’t necessarily mean that you have cancer and it doesn’t necessarily mean that you have a high-risk cancer, but if do you get a high number, we have to find out what’s going on. These are the conversations we should be having with our patients.
Follow Dr. Jazayeri at @Jazurology on twitter.
