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Active Surveillance in African-American men

Xnglei Shen

November 03, 2020

In an editorial published in JAMA, radiation oncologist Xinglei Shen, MD, weighs in on a study assessing the effectiveness of active surveillance of African-American men with early-stage prostate cancer.

Dr. Shen’s editorial accompanies a study published by researchers at the University of San Diego, Veteran’s Administration San Diego Health System and Dana-Farber Cancer Institute, which suggests that closely monitoring men with early-stage prostate cancer, rather than immediate treatment, is just as safe and effective for African-American men as it is for their white counterparts. The findings come from a retrospective analysis of 2,280 African-American and 6,446 white patients with low-risk prostate cancer who underwent active surveillance in the Veterans Health Administration healthcare system.

Active surveillance for African-American men with early-stage prostate cancer has been a source of controversy in the oncology community.

“Many studies have demonstrated that African-Americans with prostate cancer tend to have somewhat more aggressive prostate cancer, stage for stage,” Dr. Shen said. “The study addresses the question, is active surveillance, which may delay treatment, safe for African-Americans? In short, yes, it is safe and effective for this group.”

The study demonstrated that African-American men compared to white men, both under active surveillance, had similar survival rates. African-American men, however, were more likely to have disease progression and move from active surveillance to treatment.

“The study also confirms African-Americans do have more aggressive prostate cancer even in early stages,” Dr. Shen said, “However, active surveillance should still be considered for African-Americans. Four out of every 10 African-American study participants were able to avoid treatment entirely,”

Avoiding overtreatment with active surveillance

Overtreatment of prostate cancer patients is a widely recognized issue, according to Dr. Shen. Prostate cancer treatment typically involves radiation and/or a radical prostatectomy, both of which may cause serious long-term side effects. To mitigate overtreatment, men with early-stage prostate cancer can be monitored through active surveillance, a recommended standard of care.

Active surveillance is an approach in which early-stage, or low-risk, prostate cancer is not treated with radiation or surgery. Instead, the cancer is monitored very closely for signs of change or progression. Monitoring methods include regular PSA (prostate-specific antigen) testing, biopsies and physical examinations.

According to Dr. Shen, several studies have demonstrated that active surveillance spares about 50% of low-risk prostate cancer patients from treatment, with little risk of their cancer spreading.

“In some patients with low-risk prostate cancer, you can delay treatment and still achieve a high cure rate by practicing active surveillance,” he explained. “If the tumor changes or grows, you move into treatment.”

Addressing health disparities

Historically, studies determining the effectiveness of active surveillance in early-stage prostate cancer have overwhelmingly focused on white men. While these studies have resulted in a paradigm shift in treatment recommendations, they have omitted African-Americans, a group disproportionately affected by prostate cancer.

“If we skip active surveillance for all African-Americans, a large percentage of these patients may be subject to treatment they may not need,” Dr. Shen said “We tend to think of disparities in terms of someone not having access to treatment. However, disparities may also arise from overtreating African-Americans who are good candidates for active surveillance.”

A cautionary note must be raised regarding generalizing results from the equal-access Veteran Administration’s (VA) medical centers to more common healthcare settings, Dr. Shen noted in his editorial. The VA is a unique environment in that quality of care seems to be about the same, regardless of race. That is not the case outside of the VA, and how generalizable this data is to the broader population is unknown. Still, the study reveals key insights that could change the way African-American men with early-stage prostate cancer are treated.

“It’s been a huge debate – should you recommend active surveillance for African-American patients?  This study gives us more guidance on the subject and helps doctors and patients make a shared, better informed decision about the best course of treatment,” Dr. Shen said. “For the future, it is important that we keep working to have good representation from African-Americans and other minorities on clinical trials.”

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