Ethnic Differences in Prostate Cancer Presentation: A Time for Testing Advocacy

Most of our knowledge and assumptions on prostate cancer disease behaviour stem from our understanding of how the disease behaves in white Caucasians, as these populations have been studied and reported the most. However, it is now increasingly recognised that prostate cancer is protean in its presentation and behaves differently in diverse peoples and ethnicities, leading to increased scrutiny of disease behaviour in different races.

The behaviour of the disease in patients of black ethnicity has been well explored and has been frequently studied in the last few years, leading to an awareness of the higher risks. This knowledge, in turn, has led to focused efforts on ensuring equity in disease management. In our paper, we have speculated that apart from biological differences in disease behaviour, social, economic, and educational factors have a bearing on disease outcomes in various races due to variations in health-seeking behaviour, availability and affordability of health resources, and ignorance about diseases.

The UK is racially diverse and multicultural, and London is one of the world's leading melting pots. North West London has a population composed in large part of white Caucasians, Blacks from the Caribbeans and Africa, and South Asians mainly from the Indian sub-continent or Africa. It is the last group that is relatively underrepresented in epidemiological studies of prostate cancer.

It is in this context that we retrospectively studied a nine-year cohort of biopsy-diagnosed prostate cancer patients. In the UK, we capture self-reported ethnicity from our patients, and we grouped patients as per their ethnicities as South Asian (Indian, Pakistani, Nepalese or Sri Lankan), White (British, European), Black (Caribbean, African) and others (Chinese, Middle Eastern, Mixed races). We then examined their presenting PSA, Gleason score on biopsy, and UICC clinical stage and estimated their D'Amico risk score for disease recurrence. It is pertinent to note that the UK does not have a prostate cancer screening program, so we also examined the data to see if the patients were referred due to high PSA values or for other reasons.

From an eligible biopsy-diagnosed patient base of over 1300 patients, we had 1176 patient records. Our results showed that Black men had a significantly lower average age at presentation and diagnosis. Presenting PSA did not differ significantly between the ethnicities that we studied. Most of our patients had a Gleason score of 7, and 65-71% were at high risk for recurrence, with whites having the lowest proportion of high-risk patients (65%) and South Asians the highest (71%). Interestingly, South Asian men also had the highest percentage with advanced Gleason scores and were the least likely to be diagnosed by PSA testing alone.

Despite study limitations, our paper underscores the point that ethnic variations on prostatic cancer need to be studied further to develop targeted interventions that are more suitable to various races and ethnicities, such as focusing on the lower rates of South Asian men's use of PSA testing to improve early diagnosis rates.

Written by: Deepak Batura, MBBS, MS, MCh, FRCS, Department of Urology, London North West Healthcare NHS Trust, Watford Road, London, UK

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