The Surveillance, Epidemiology, and End Result cancer registry has demonstrated a consistent and markedly higher rate of prostate cancer mortality among Black men in the U.S. since the 1970s.¹ Black men are 80% more likely to be diagnosed with prostate cancer in the U.S. and twice as likely to die from prostate cancer as their non-Black male counterparts.¹ This represents the widest racial inequity in cancer-related death in the U.S.² Despite markedly higher rates of incidence and death, the lack of recommendations to guide care among Black men has often been justified by a lack of level 1 evidence to support a targeted intervention. This is largely due to Black men being historically excluded and/or underrepresented in the most of the seminal trials in prostate cancer, where Black men have represented 3% or fewer of study cohort populations.³ The lack of representation in clinical trials influencing policy and guidelines is perhaps best exemplified in the U.S. Preventive Services Task Force’s latest recommendation, which states that “it is problematic to selectively recommend [prostate specific antigen]-based screening for Black men in the absence of data that support a more favorable balance of risks and benefit.”⁴

Various high-level qualitative secondary data analyses have demonstrated that strategies such as earlier screening⁵ and “equal-access” to high quality local therapy^6,7 can reduce the large racial gap in prostate cancer death. However, studies to evaluate how structural/social determinant of equity (ie systemic racism, economic policies, public policies), social determinants of health and health services may improve prostate cancer outcomes for Black men in the U.S. remain scarce. Obtaining evidence to support targeted interventions means the design of studies that do not simply aim to have representative samples of Black men, but instead studies that allow for robust comparative analysis (ie comparable samples) or evaluation of interventions in cohorts exclusively comprised of Black men. If we hope to create high-quality evidence that thoroughly evaluates the benefits, harms, and costs of social and health interventions within specific populations then we must re-define what the standard is for the cohorts we build and study.

But how do we overcome a long-standing history of exclusion, distrust, experimentation and abuse of marginalized populations to create equity for high-risk, marginalized and often vulnerable populations like Black men with prostate cancer? Recent translational health services research in bladder cancer has demonstrated a pathway for utilizing a community-engaged and patient-centered approach for translating patient and community priorities for care into the design and execution of large multi-institutional clinical trials and clinical interventions.^8,9 This approach, which utilizes relationships with cancer survivors, advocates and support networks, is built on the fundamental tenets of partnership, collaboration and trust as the key drivers of identifying research priorities, designing clinical trial and research studies, and translating health services interventions into clinical practice. This patient-centered approach to health services research also allows for survivors, advocates and support system members to be trained as community researchers, which is an empowering act that adds value to the community and our research teams.^10,11

For racial inequities in prostate cancer, this means defining our clinical and health services questions in an iterative and collaborative process that relies heavily on input from Black men and their support networks from inception through the development and execution of clinical and health services research studies. These research priorities/questions can then be evaluated critically in the current literature to determine if higher quality data are needed–ie designing and executing patient-centered trials/studies–or if a health service intervention can be developed using the existing literature. By centering our efforts around Black men, as true research partners, we do the hard work of building the relationships, resources and skill sets needed to collectively advance our research efforts to create parity in prostate cancer outcomes. And in doing so we raise the quality of care we provide for all men with prostate cancer.

Acknowledgements

I thank my community partners at the Black and African descent Collaborative for Prostate cancer ACtion (BACPAC): Mr. Ben Young, Mr. Victor Tolbert and Mr. Dante Morehead (https://www.bacpacnetwork.org) for their continued collaboration and support. I also thank Drs. Ruth Etzioni, Angela Smith and John Gore for their mentorship and sponsorship.