American Indian and Alaska Native (AI/AN) men have more advanced prostate cancer at time of diagnosis, receive lower rates of definitive treatment, and experience higher mortality rates than any other racial group. Well publicized in the general medicine and urological literature—and even in lay literature—has been the increased vulnerability of African American and Hispanic minorities to prostate cancer. Conversely, an AUANews article published in 2005 had concluded that only a scant amount of attention was then being given to the problem of prostate cancer among Native American men.¹ Sadly, nearly 20 years later, this discrimination still remains largely unaddressed.

As is the case for African Americans, especially those living below the poverty level, AI/AN men and women are more likely, in general, to have more advanced cancers at the time of their diagnosis, are less likely to be afforded the option of curative surgery, are more likely to be relegated to temporizing medical therapy, and are more likely to experience progression of their cancer. As a result, in the specific case of prostate cancer, despite its low incidence in this population, some studies have shown it to be the second most common cause of cancer death among AI/AN men.

The increased prostate-cancer mortality for AI/AN men is due primarily to delays in diagnosis and to lack of access to effective treatment, rather than to any unique racial predisposition. The percentage of AI/AN men who first present with disease that is already metastatic is double that for Caucasian men. Researchers urge that efforts be made to diagnose prostate cancer in AI/AN at an earlier and more favorable stage comparable to that for Caucasian men.²

Detection is impaired by low screening rates. A CDC review found that AI/AN men had markedly lower rates of prostate screening, compared to African American and White men. Moreover, while there was a significant increase in screening among white men and African Americans over a 12-year period, there was no such increase among AI/AN. These researchers concurred that these disparities in outcome were not disease- or race-related but were rather the reflection of socioeconomic factors—lack of cancer-care service, language differences, illness beliefs, limited knowledge of cancer care, negative attitude towards cancer treatment, transportation difficulties, and perceived discrimination by health care providers. They contended that programs and policies need to be better tailored to the unique needs of AI/AN populations, which are culturally diverse and face a wide range of different barriers to health care access.³

A more recent analysis once again indicates that disparities in access appear to account for this excess in poor outcomes. These researchers found that, where mortality rates from prostate cancer had declined for White men between 1999 and 2009, they had remained relatively constant among AI/AN men. With the advent of a recommendation for expanded prostate-specific antigen screening, the early detection of prostate cancers in AI/AN men did modestly increase from 2014 to 2017, but the incidence of distant disease also increased. Overall, AI/AN men have experienced the smallest decrease in overall prostate-cancer mortality rates among all major racial and ethnic groups in the United States.⁴

The authors of this study conclude that, after adjusting for clinical and pathological factors, county-level demographics, and provider density, there were no differences between these patients and White patients. Thus, social and economic inequities, rather than disease-specific factors, are largely responsible for these disparities. Focused health-policy interventions remain much needed.⁴

Yet another concurrent study has found that racial/ethnic disparities persist in patients with prostate cancer in the US. The continued disparity in all-cause and cause-specific mortality, particularly among Black and AI/AN patients, as compared to White patients, highlights the need for stronger measures to address these inequalities. Factors such as socioeconomic status, stage at diagnosis, and initial treatment have contributed to these disparities. Changes in prostate-specific antigen screening guidelines made a big impact in the trends and patterns of racial/ethnic disparities. However, it is also important to acknowledge that the long history of structural racism and social injustice has perpetuated adverse social determinants of health, leading to persistent racial/ethnic disparities in health care.⁶

Raising prostate cancer awareness among AI/AN men themselves remains another unmet need. To this day, few efforts have been aimed at reaching out to Native Americans with literature or online communication specifically relevant to them. One notable exception had been a single pamphlet from Zero Cancer/Us Too International, “American Indian Men, Alaskan Native Men, and People Who Care about Them.” This pamphlet provided information, which was oriented specifically toward Native American men, regarding prostate cancer and the importance of screening. It also included contact information regarding (1) Native American Cancer Research and (2) the National Indian Health Board. Even this one pamphlet has now been discontinued.

Databases assessing discrimination in the health care delivery systems in the US indicate that African Americans are often marginalized or even excluded from care. Worse still, however, AI/AN data are often subsumed under the “Other” category or even omitted entirely from these databases!⁴ When addressing cancer-care disparities in the treatment of ethnic minorities, rather than masking or excluding AI/AN data, we should be giving priority attention specifically to these, our country’s first Americans. There is no “Other” quite like them.⁵

All too often and in so many ways, America’s first people are the last to receive the attention they deserve. Native American men and women, by virtue of their vulnerability and heritage, merit our focused concern. First American men must no longer be the last to receive the best in prostate cancer awareness, detection, treatment, and cure.