PROSTATE CANCER Disparities in Prostate Cancer: Nature or Nurture or Both?

By: Brian Keith McNeil, MD, MBA, FACS, SUNY Downstate Health Sciences University, Brooklyn, New York | Posted on: 07 Sep 2023

September is a meaningful month for several reasons. I can recall my excitement as a child energized from the beginning of the academic school year. My mother was born in September and I can’t tell you how many odd jobs I’ve worked to save money to purchase a gift for her to open on the morning of her birthday. I started off as an aspiring carpenter before working as a gardener, telemarketer, and night shift Philadelphia Tastykake factory worker. If I called you trying to get you to expand your basic cable service or asking you to answer survey questions during the 1990s, please forgive me!

As a urologist in training, September became even more meaningful after the United States Senate passed Senate Resolution 138 on August 3, 2001, designating the month of September as National Prostate Cancer Awareness Month. Since then, I have used September as a marker of where we are as a field regarding prostate cancer disparities. I have long been aware that I carry 2 risk factors for the development of prostate cancer, as a Black male whose father succumbed to prostate cancer. One of the things I was taught early on during my training was that Black men had a higher risk of prostate cancer and that our outcomes were typically worse compared to other groups. Considering my lived experience with my father, I often wondered whether disparities in prostate cancer were rooted in nature, nurture, or both.

The number of investigators in our field working to address this issue has multiplied over the years. A recent PubMed search for “Prostate Cancer Disparities” yielded 1,983 results. The yearly output has increased from 6 in 2001, the year that I graduated from medical school, to 236 in 2022. This reflects a greater focus on disparities and what they mean for not only the Black community, but other communities underrepresented in medicine.

We have made significant progress in reducing cancer mortality in the United States over the last 25 years. Investigators from the American Cancer Society shared our progress in reducing cancer mortality in the United States by congressional district from 1996-2003 compared to 2012-2020.1 Prostate cancer death rates substantially declined in each congressional district with relative decline ranging from 25% to 68.3%. Among Black males, congressional districts with the highest death rates were scattered across the United States during both periods. However, there now appears to be a greater concentration in the South. Prostate cancer outcomes have more than we previously thought to do with factors unrelated to nature.

One of the most interesting reports I have read over the last year was a manuscript published in Journal of Clinical Oncology titled “Racism Does Not Cause Prostate Cancer, It Causes Prostate Cancer Death.” The authors highlighted evidence from epidemiological and genetic studies that the increased incidence of prostate cancer in Black men is rooted in genetics. Nevertheless, the effects of racism influence the chances that someone will die as a result.2

Disparities in prostate cancer exist among men who are part of the Hispanic, American Indian, and Alaskan Native communities.3 They often present with more advanced disease, have lower rates of definitive treatment, suffer higher mortality, and reside in areas with less access to specialty care. Racial inequities have been shown to exist in the surgical care of Medicare beneficiaries with localized prostate cancer.4 A recent meta-analysis revealed that Black and Hispanic men remain underrepresented in prostate cancer clinical trials.5 Advocacy remains one of the keys to addressing disparities in prostate cancer.6 Advocacy at the local, regional, and national level can have a profound impact on disparities in not only prostate, but other urological conditions. I encourage interested readers to consider attending the 2024 Annual Urology Advocacy Summit on Capitol Hill.

There is much work to do to address disparities in prostate cancer. Some evidence has shown that addressing disparities with one group could have an overall positive impact on the health of all. I believe that disparities in prostate cancer are not rooted in nature or nurture alone, but both. With further investigation of social determinants of health and targeted interventions we can contribute to the overall well-being of society. Our colleague, Dr Willie Underwood, is leading a broad discussion surrounding the impact of health care disparities in his current role as Chair of the American Medical Association Board of Trustees. I have been particularly encouraged by the actions of the Urology Care Foundation under the leadership of Dr Harris M. Nagler. The inaugural Urology Care Foundation Health Equity Fellowship, awarded to rising star Dr Randy Vince, will allow Dr Vince to continue his innovative work exploring social determinants of health and prostate cancer disparities.7 Let’s all support Dr Vince and others who are interested in this work. I make this plea, not as a fellow urologist, but as a member of a high-risk population and humble servant trying to help families that may suffer due to the loss of a loved one sooner than necessary.

  1. Islami F, Wiese D, Marlow EC, et al. Progress in reducing cancer mortality in the United States by congressional district, 1996-2003 to 2012-2020. Cancer. 2023;129(16):2522-2531.
  2. Vickers AJ, Mahal B, Ogunwobi OO. Racism does not cause prostate cancer, it causes prostate cancer death. J Clin Oncol. 2023;41(12):2151-2154.
  3. Chu CE, Leapman MS, Zhao S, Cowan JE, Washington SL, Cooperberg MR. Prostate cancer disparities among American Indians and Alaskan Natives in the United States. J Natl Cancer Inst. 2023;115(4):413-420.
  4. Nyame YA, Holt SK, Etzioni RD, Gore JL. Racial inequities in the quality of surgical care among Medicare beneficiaries with localized prostate cancer. Cancer. 2023;129(9):1402-1410.
  5. Riaz IB, Islam M, Ikram W, et al. Disparities in the inclusion of racial and ethnic minority groups and older adults in prostate cancer clinical trials: a meta-analysis. JAMA Oncol. 2023;9(2):180-187.
  6. Pittman A, Moses KA, Washington SL III. Urologists in advocacy: the key to addressing disparities in prostate cancer. J Urol. 2023;209(1):27-28.
  7. Vince RA Jr, Jiang R, Bank M, et al. Evaluation of social determinants of health and prostate cancer outcomes among Black and White patients: a systematic review and meta-analysis. JAMA Netw Open. 2023;6(1):e2250416.