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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.
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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.
Long-Term Study Informs Decision-Making On Prostate Cancer Treatment
SIDE effects and treatment options in prostate cancer have been illuminated by a recent study involving a 10-year follow-up in American males. The CEASAR study is a multi-centre research project, which studies males who were diagnosed with prostate cancer between 2011–2012.
Having followed the cohort for over a decade, the findings from this research bring to light some important points to consider. They highlight "the benefits of active surveillance, when oncologically safe for patients with favourable-prognosis prostate cancer, by avoiding adverse effects associated with other treatment options," stated Daniel Barocas, Vanderbilt University Medical Center (VUMC), Amsterdam, the Netherlands.
The current study is based on a population of 2,500 patients, comprised of 1,797 non-Hispanic White males, 350 non-Hispanic Black males, 184 Hispanic males, 77 Asian males, and 33 in an 'other' race category. This investigation administered a series of questionnaires regarding urinary, bowel, sexual, and hormone therapy-related side effects of treatment. Patients were classified based on cancer risk into two categories: favourable prognosis, and unfavourable prognosis, receiving more intensive treatment. The favourable prognosis group was given the choice of active surveillance, nerve-sparing prostatectomy, external beam radiation therapy, or low-dose-rate brachytherapy. Meanwhile, individuals with unfavourable-prognosis decided on either prostatectomy, or external beam radiation therapy with androgen deprivation therapy (ADT).
Key findings from the research included discovery that surgery with radical prostatectomy was associated with an increased risk of urinary incontinence over 10 years, when compared with other treatments, irrespective of cancer risk. Patients with favourable cancer prognoses experienced worse sexual impairment for the first 3–5 years following surgery with radical prostatectomy when compared to other options. Sexual function scores were similar across treatments after 5 years, likely reflective of age-related decline, gradual decline associated with radiation, and conversion from active surveillance treatment. No significant differences in sexual function impairment were found between surgery with radical prostatectomy and radiation with ADT, in patients with unfavourable prognosis. Finally, radiation therapy combined with ADT was associated with slightly worse bowel and hormone functions at 10 years in the unfavourable prostate cancer group.
These conclusions are expected to guide treatment options and decisions in clinical practice, providing informed longitudinal data. In follow-up, the authors are developing a personalised, predictive tool using the collected data to offer functional estimates to patients based on different treatment strategies, to help further with their decision-making.
Hormone Vs. Nonhormone Therapies For Advanced Prostate Cancer
Hormone therapy works by decreasing the hormones in your body that encourage prostate cancer to multiply. Nonhormone therapies focus on killing existing cancer cells.
If prostate cancer reaches an advanced stage and cancer cells have spread to other parts of the body, you will need treatment. Watchful waiting, which may have been your doctor's first course of action, is no longer an option.
People with advanced prostate cancer now have more available treatment options than ever before. These include both hormone therapies and nonhormone treatment options.
The exact treatment you'll receive depends on your stage of prostate cancer and any underlying conditions you have. Remember that your treatment experience can be quite different from someone else's.
To decide on a treatment, you'll need to consider the overall goal of the treatment, its side effects, and whether you're a good candidate. Being informed about the available treatments can help you and your doctor decide which treatment, or combination of treatments, is best for you.
Hormone therapy is also known as androgen deprivation therapy (ADT). It's often considered a key treatment for metastatic prostate cancer.
How hormone therapy worksHormone therapy works by decreasing the levels of hormones (androgens) in the body. Androgens include testosterone and dihydrotestosterone (DHT). These hormones encourage prostate cancer to multiply. Without androgens, tumor growth is slowed and the cancer may even go into remission.
Approved hormone treatmentsSeveral approved hormone treatments exist for prostate cancer. These include:
The goal of hormone therapy is remission. Remission means that all of the signs and symptoms of prostate cancer go away. People who've achieved remission aren't "cured," but they can go many years without showing signs of cancer.
Hormone therapy may also be used to reduce the risk of recurrence after preliminary treatment in men who are at a high risk of recurrence.
How treatments are givenHormone treatments differ in how you receive them.
A chemotherapy drug called docetaxel (Taxotere) is sometimes used in combination with hormone therapies.
Surgery to remove the testicles can be done as an outpatient procedure. You should be able to go home a few hours after an orchiectomy.
Candidates for hormone therapiesMost people with advanced prostate cancer are candidates for hormone therapy. It's usually considered when prostate cancer has spread beyond the prostate, and surgery to remove the tumor is no longer possible.
Prior to starting treatment, you'll need to have a liver function test along with a blood test to make sure your liver can break down the medications properly.
Currently, enzalutamide (Xtandi) is only approved for use in people with prostate cancer that has already spread to other parts of the body, and when the body no longer responds to medical or surgical treatments to lower testosterone levels.
In some cases, prostate cancer cells can resist hormone treatments and multiply even in the absence of male hormones. This is called hormone-resistant (or castration-resistant) prostate cancer.
People with hormone-resistant prostate cancer can no longer remain on monotherapy (one hormone therapy alone) because it will allow their testosterone to return to typical levels and fuel cancer growth. In these instances, doctors will usually also prescribe a pill that blocks the androgen or its receptor in order to get a positive response from treatment.
Common side effectsThe most common side effects of hormone therapies include:
If hormone treatment isn't working or your cancer is growing and spreading too quickly, treatment with other nonhormone options may be recommended.
Approved nonhormone treatmentsNonhormone treatments for advanced prostate cancer include:
Treatment goalsThe goal of chemotherapy, radiation, and other nonhormone treatments is to slow down the growth of the cancer and extend a person's life.
Chemotherapy and other nonhormone treatments probably won't be able to cure the cancer, but they can significantly prolong the lives of people with metastatic prostate cancer.
Candidates for nonhormone therapyYou may be a candidate for nonhormone treatments such as chemotherapy or radiation if:
Chemotherapy is generally given in cycles. Each cycle typically lasts a few weeks. You might need multiple rounds of treatment, but there's usually a period of rest in between. If one type of chemotherapy stops working, your doctor may recommend other chemotherapy options.
Sipuleucel-T (Provenge) is given as three infusions into a vein, with about 2 weeks between each infusion.
Radium Ra 223 is also given as an injection.
Common side effects of chemotherapyCommon side effects of chemotherapy include:
Radiation treatments can reduce your red blood cell count and cause anemia. Anemia causes fatigue, dizziness, headache, and other symptoms. Radiation treatment can also lead to incontinence (loss of bladder control) and erectile dysfunction.
If left untreated, most cases of prostate cancer will spread beyond the prostate to local tissues and organs. However, not all cancers are the same.
Some people with low or intermediate risk of cancer progression can take an active surveillance or "wait and see" approach. In some of these cases, the cancer may never spread or cause symptoms.
However, treatment should be considered if the cancer begins growing outside the localized area within the prostate or starts to cause symptoms.
How long can a man live with prostate cancer without treatment?A 2023 study found that 97% of people diagnosed with localized prostate cancer lived 15 years after diagnosis, regardless of whether they received surgery, radiation therapy, or active monitoring.
Can you treat prostate cancer without hormone therapy?Yes. A doctor may decide to treat prostate cancer with nonhormone therapy such as surgery, radiation therapy, and chemotherapy. Nonhormone therapy is typically used when a cancer is growing and spreading too quickly or if the cancer has become resistant to hormone therapy.
What is the best hormone therapy for advanced prostate cancer?Most people with advanced prostate cancer have hormone therapy. Doctors may prescribe a combination of different hormone therapy drugs or hormone therapy with chemotherapy.
Nonhormone therapies are a good option for people with advanced prostate cancers that no longer respond to hormone treatments alone.
What stage of prostate cancer requires hormone treatment?Prostate cancers need male sex hormones called androgens to grow. Hormone therapies that decrease androgen levels or block their growth are often used for early stage prostate cancers.
If the cancer starts spreading or has spread beyond the prostate (later stage cancers), doctors may recommend nonhormonal treatments, such as surgery, chemotherapy, or radiation treatment, with or without hormone therapy.
Hormone therapies and surgeries are typically recommended first to treat advanced prostate cancer.
Generally, prostate cancer is controlled the longest while on anti-androgen (hormone) therapies. However, when resistance to hormone manipulation sets in, a doctor might recommend chemotherapy, immunotherapy, and radiotherapies (either Radium 223 or Lutetium-177 vipivotide tetraxetan PSMA therapy) to try and manage the cancer temporarily.
Even with treatment, most cases of advanced prostate cancer cannot be cured. But treatments can slow the growth of the cancer, reduce symptoms, and improve survival. Many people live for years with advanced prostate cancer.
Making decisions about treatments can be confusing and challenging because there's a lot to consider. Remember that you don't need to make the decision alone. With guidance from your oncologist and medical care team, you can make an informed decision on the best treatment plan for you.
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