Prostate cancer screening in African American and Caribbean males: detriment in delay

ABNF Journal, The, Nov-Dec, 2004 by Yvonne D. Parchment

Prostate cancer, is the most frequently diagnosed cancer in the United States, accounting for 33% of all cancer ,re. cases among men (American Cancer Society, 2004), and is the second leading cause of cancer death in men in the U.S. (American Cancer Society, 2004). In comparison with Caucasian males, African American men are diagnosed with prostate cancer much later, and the mortality rate is 2.4 times higher among African Americans than Caucasians (American Cancer Society, 2004). The age-adjusted incidence of prostate cancer is 225/100,000 among African Americans compared with 149/100,000 among White, non-Hispanics (Ries, Eisner, Kosary, Hankey, Miller, Clegg et al., 2000). In Florida, the American Cancer Society estimates that 17,090 new cases of prostate cancer will be diagnosed in 2004 and that 2,220 will die of the disease (American Cancer Society, 2003). This difference in diagnosis and mortality is likely due to African American men delaying or avoiding screening and health disparities in access to care (Sellers & Ross, 2003).

In addition to the high rates of prostate cancer among African American men in the U.S., other men of the African diaspora have prevalence rates significantly higher than that found among Caucasian men in the U.S. In a study among predominantly African-descended men in Tobago, the screening-detected prevalence rates was 15.1 of 100 compared with a primarily Caucasian U.S. sample of 3.8 of 100 (Bunker, Patrick, Konety, Dhir, Brufsky, Vivas et al., 2002), though the authors note that procedural differences, e.g., increased biopsy rates, may partially explain the difference. The authors also compared their results with the findings of a U.S. study among African Americans and suggest that the Tobago rate may be twice that of the African American rate. In another study, age-adjusted incidence in Kingston, Jamaica was calculated at 304/ 100,000 (Glover, Coffey, Douglas, Cadogan et al., 1998). These rates were found to be higher than among African American men during a similar time period and with greater morbidity. Later diagnosis of prostate cancer in Jamaica may partially explain these elevated rates among the Jamaican sample (Coard, 2002). Although much research to date points to differences between Caribbean and American men of African descent, one study found that serum levels of PSA were similar among U.S.--born and Jamaican-born Black men (Chen, MacChia, Conway, Magai, Desai, & Neugut, 2004).

Bunker and others (2002) suggest that African descended men share common genetic or familial factors that may increase vulnerability to prostate cancer. For example, studies of family history in Jamaica show that a man with an affected first degree relative is twice as likely to develop prostate cancer (Glover et al., 1998). However, within the diaspora, there is wide variation, suggesting the importance of environmental and lifestyle factors (Brawley, Knopf, & Thompson, 1998). Researchers have hypothesized that other risk factors may include age, and a high-fat or meat diet (Ross & Schottenfeld, 1996).

In addition to environmental and genetic factors, studies suggest that disparities in healthcare access and care may account for some of the variability in outcomes. For example, research has found that Hispanic and African American men received less medical monitoring and had a longer time from diagnosis to medical visits than Caucasian men (Shavers, Brown, Klabunde, et al., 2004), and were also more likely to receive watchful waiting as opposed to a more proactive treatment protocol (Shavers, Brown, Potosky et al., 2004). Reddy, Shapiro, Morton, and Brawley (2003) in summarizing some of the literature report that differences in patterns of care by race may contribute to the findings of racial disparity in survival after diagnosis of prostate cancer. Where disparities in access and care are minimized, for example in the military, research found that African American men in the military exhibited reduced risk for prostate cancer compared to non-military African American men (Sanderson, Coker, Logan, Zheng, & Fadden, 2004).

BARRIERS TO ACCESS AND CARE

Many studies have examined the barriers to access and care among ethnic minority patients in the U.S. Important factors include structural barriers and those related to education and resources, fears related to treatment outcomes, and lack of cultural sensitivity on the part of healthcare professionals when approaching these issues with minorities. Plowden (1999) assessed five variables in prostate cancer screening in African American men--perceived susceptibility, perceived severity, perceived benefits, perceived barriers and cues to action--and found that men will seek screening if these five variables are addressed by healthcare professionals. Shelton, Weinrich, and Reynolds (1999) found that the five most common barriers to prostate screening among African American men were lack of knowledge about the need for screening, lack of finances, lack of insurance, not knowing which physician to see for screening, and lack of information about the availability of free screening. And Watts (1994) found that African American men delayed or avoided screening because of expected discomfort and a lack of knowledge about the benefits of current therapeutic modalities.