12 Health Screenings Women Should Consider
Black Men With Advanced Prostate Cancer Are Less Likely To Get The Most Effective Therapies
About 1 in 8 men will be diagnosed with prostate cancer in his lifetime.[1] Although prostate cancer is the second leading cause of cancer death in men, behind only lung cancer, the average patient with prostate cancer will not die from the disease.
[1] Recent advances in treatment, notably the new hormone therapy agents enzalutamide (Xtandi), apalutamide (Erleada), and darolutamide (Nubeqa), have extended the lives of people with advanced prostate cancer.
[2]
But for certain patients, the statistics are not quite as rosy. Black men are 1.5 times as likely as white men to be diagnosed with prostate cancer in the United States, and advanced prostate cancer is 2.4 times more lethal in Black men than in white men.[3] Could differences in the use of these novel hormonal therapies play a role in this discrepancy in mortality rates? A study published in December 2023 in JAMA Network Open discovered that despite their proven benefits, these novel hormone therapies are not prescribed at the same levels for men of different races, with a significantly lower rate of use in Black men.
Novel Hormone Therapy Is More Effective Than Traditional Therapy in Advanced Prostate Cancer Because male sex hormones called androgens are responsible for the growth of prostate cancer, treatment involves lowering the levels of these hormones.[4]
In traditional hormone treatment for prostate cancer, known as androgen deprivation therapy, a drug is administered to shut down the production of testosterone, the main androgen.[4] "That is still the foundation of hormonal treatment of prostate cancer," says Michael Xiang, MD, PhD, an assistant clinical professor of radiation oncology at the David Geffen School of Medicine at UCLA and an author of the study.
However, the newer hormone therapies in question, known as second-generation androgen receptor inhibitors, are especially effective at stopping cancer growth when used with traditional androgen deprivation therapy. These novel therapies "inhibit the synthesis of testosterone or cause its direct blockade," Dr. Xiang says.
The problem is that Black men with prostate cancer are not taking these therapies at the same rates as other men are. Xiang's study found that Black men with advanced or high-risk prostate cancer had the lowest two-year utilization rate of these therapies compared with white men, Hispanic men, or men of other races and ethnicities.
Xiang and his colleagues examined records from 3,748 men with prostate cancer who were on Medicare between 2011 and 2017. In any two-year period during the study, white men received one of these drugs at a rate of 27 percent, Hispanic men at a rate of 25 percent, and men of other races or ethnicities 23 percent. Black men received these therapies at a rate of 20 percent over any two years, a significantly lower rate of use. And this difference held steady over the entire period of the study.
Disparities Caused by Systemic Inequalities, Provider Bias, and Barriers to CareWhy are Black men much less likely to be prescribed these novel hormone therapies? Xiang feels that systemic inequalities in the healthcare system may be to blame. "Part of it could be provider-related implicit biases," he says. "Possibly, some providers are just less inclined to think of [novel therapies] for underserved populations."
The gap could also have to do with the patient's factors, he notes, such as lack of knowledge and education, reduced access to care, insufficient insurance coverage, or a dearth of financial resources.
Xiang acknowledged that it's possible that some Black patients might have been offered these therapies but declined them because of distrust of medical providers and the medical community, which has historically been common among Black people.
How Can This Pattern Be Changed?Equity in prescribing novel hormone therapies needs to start with physicians. "Ideally, all doctors would stay up to date with the current evidence and the current guidelines," Xiang says. He stresses that providers need to be mindful about applying the same guidelines and recommendations to all of their patients, although some cases may be complicated by the fact that copays for certain medications and procedures can be prohibitive, and the type of insurance a patient has may impact the care they receive.
One important way that people can optimize their outcomes, according to Xiang, is to be proactive about screening and testing protocols for prostate cancer. "It's something to discuss with one's primary care doctor," he says. "I think some of the racial or ethnic disparities around prostate cancer might stem from differences in screening patterns."
He adds that patients can educate themselves on newer therapies for their condition and ask their physicians about trying them.
Unfortunately, failure to receive one of these newer hormone therapies during prostate cancer treatment tends to lead to worse outcomes. The study did not examine survival rates, but Xiang notes that lower survival rates is a logical conclusion. Until Black men receive this therapy at the same rate as other men, these outcomes may not improve.
Bone Biomarkers Predict Survival In Hormone-Sensitive Prostate Cancer
High levels of bone turnover biomarkers predict shorter overall survival in men with newly diagnosed metastatic hormone-sensitive prostate cancer, not just castration-resistant disease, a new study finds.
Investigators assessed biomarkers of bone formation (C-terminal collagen propeptide [CICP] and bone alkaline phosphatase [BAP]) and bone resorption (C-telopeptide [CTx] and pyridinoline [PYD]) at baseline in men in the SWOG S1216 trial. Using a training set of 316 patients, the investigators used models to determine prognostic thresholds for each biomarker and validated these thresholds in 633 patients.
Men with high vs low BAP had a significant 43% increased risk of all-cause mortality, Primo N. Lara Jr., MD, of the University of California Davis Comprehensive Cancer Center, Sacramento, California, and colleagues reported in European Urology. Median overall survival was 3.3 vs 6.8 years. High vs low CICP was significantly associated with a 92% increased risk of all-cause mortality. Median overall survival was 2.4 vs 7.6 years.
High vs low CTx was significantly associated with a 37% increased risk of all-cause mortality. Median overall survival was 4.0 vs 7.7 years. High vs low PYD was significantly associated with a 77% increased risk of all-cause mortality. Median overall survival was 3.4 vs 8.2 years.
"Elevated levels of each of the four bone biomarkers — using cut-points derived from a training set and subsequently tested in a validation set — showed statistically significant association with worse survival outcomes, independent of traditional clinical risk factors," Dr Lara's team wrote.
The investigators distinguished low-, intermediate-, and high-risk groups based on a combination of 2 of these bone biomarkers. Median overall survival was 8.2, 5.1, and 2.1 years, respectively. Median all-cause mortality was significantly increased 1.4- and 2.2-fold for the intermediate- and high-risk groups, respectively, compared with the low-risk group.
The low-risk group had a CTx less than 0.6 ng/mL and CICP less than 161 ng/mL. The intermediate-risk group had a CTx less than 0.6 ng/mL and a CICP of 161 or greater or a CTx of 0.6 ng/mL or more and a CICP less than 286 ng/mL. The high-risk group had a CTx of 0.6 ng/mL or more and a CICP of more than 286 ng/mL.
"These results can be employed by clinicians in counseling patients and by researchers in the design and conduct of future trials," Dr Lara's team wrote.
Disclosure: This research was partly supported by Millennium Pharmaceuticals. Please see the original reference for a full list of disclosures.
Initial Assessment Of Safety And Clinical Feasibility Of Irreversible Electroporation In The Focal Treatment Of Prostate Cancer
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