Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death.

Dr Martin Luther King Jr¹

The Need for Prostate Cancer Screening

On March 25, 1966, Dr Martin Luther King Jr spoke at the annual meeting of the Medical Committee for Human Rights in Chicago.¹ Today, 58 years after that famous speech, in the US we still face one of the main issues as a nation—basic access to health care among minorities. Health disparities in prostate cancer (PCa) reflect the complex interplay between socioeconomics, environmental factors, and biology. Black men suffer the highest PCa incidence and mortality in the US.² Among the Hispanic/Latino groups, Puerto Rican men have higher PCa mortality compared to non-Hispanic white men or Hispanic/Latino men living in the continental US, being second only to Black men.³ Despite the striking evidence, screenings among these groups are the lowest. PCa screening through PSA, for example, has been debated for years because of the uncertainty surrounding its benefits, risks, and the optimal screening strategy.⁴ In 2012, the US Preventive Services Task Force recommended against PSA screening for all men due to the perceived harms outweighing reported survival benefits. In 2018, these recommendations evolved into a shared decision between patients and their doctors.⁵ Similarly, the AUA recommends that physicians engage in shared decision-making with patients about PSA screening.

The Challenges

The previously mentioned recommendations have created a challenge for health care providers as well as patients, since they do not offer targeted strategies for individuals at the highest risk of developing PCa, including Black men and other populations with increased African ancestry such as Puerto Ricans. As an example, decision-making for PCa screening may be challenging for Hispanic/Latino men as they may be more likely to experience barriers related to not having a usual source of primary care, lack of availability of in-language materials and care providers, and lack of training for culturally competent care communications. In addition to issues regarding access to care, the Hispanic/Latino group is a highly diverse group, and more recent efforts have focused on subdividing Hispanics/Latinos based on country of origin. This is a significant challenge in the field of health disparities. Based on stratified studies, Hispanics/Latinos have shown the lowest rates of PSA screenings^5-8 and a higher proportion of cases diagnosed with advanced stages, along with other comorbidities.

Another important contributor to PCa-related inequities is cultural disbelief. Strikingly, little is known about the effect of culture on health-seeking behaviors and disconnectedness among Black men and other men of African ancestry. As an example, a longitudinal study exploring PCa screening behaviors among 277 participants⁹ showed that Black men view cultural knowledge among health care providers as a sign of acceptance of Black values and an openness to having Black people engaged in meaningful and respectful ways within the system. The role of genetic ancestry and PCa risk among US Hispanics/Latinos has been explored in limited studies. A study performed in Puerto Rico replicated the association between a single-nucleotide polymorphism of African ancestral origin and PCa risk, suggesting a possible association between African local ancestry and PCa risk.¹⁰

Community-Based Interventions, A Powerful Tool Against PCa

National interventions are needed to tackle the complex reasons for the existing PCa mortality disparity for high-risk populations. Strategies are varied and include education of lawmakers on the current health care disparities, identification of barriers and needs of the upcoming generation of urologists, the development of culturally appropriate evidence-based interventions, fostering strategic collaborations, and increasing the participation of these populations in clinical trials with the long-term goal to improve health equity.¹¹ Additionally, there is a tremendous opportunity to leverage community partnerships to provide education and PCa screening with PSA testing in untapped and underserved communities. Through screening and detection of PCa at an early and curable stage at a widespread community level, there is potential to reduce PCa mortality in a meaningful and measurable way. This is especially relevant as studies repeatedly show that Black men continue to be less likely to be screened as well as less likely to be offered screening tests by their clinicians.¹²

In response to this reality, the authors and their teams have developed successful community-based PCa screening programs that have been implemented on the West (Figure 1) and East (Figure 2) Coasts of the US. These initiatives have provided free point-of-care PSA testing to 2,000 Black and Hispanic/Latino men in Los Angeles, California, and Atlanta, Georgia. Screenings have been administered to target populations at health education events in collaboration with community-based organizations, including churches, grassroots advocacy groups, cancer survivor programs, city departments, barber shops, fraternities, and community clinics. The programs have provided health education about PCa and the PSA test before screening is conducted. The success of these programs has been contingent upon secured memorandums of understanding with area clinical partners and safety net hospitals in the catchment area of target populations because it creates a referral network for men who need follow-up cancer care regardless of insurance status. Pre- and post-assessments of PCa knowledge have been utilized to evaluate the measurement of program impact. In addition to detecting elevated PSA levels in a varying number of screened men, the programs have also been able to raise awareness about the importance of diverse representation in PCa clinical trials as well as communicate several current clinical trials available for men already diagnosed with PCa.

Conclusions

On January 22, 2024, a week after Martin Luther King Jr Day, the son of the late civil rights movement leader and American civil rights activist, Dexter King, passed away after 3 years of battling PCa. Now more than ever, there is a need to create awareness of the disparities associated with PCa, especially the lack of early detection among Black men and Hispanics/Latinos with higher African ancestry. The best way to fight PCa is with early detection and education.

Support: This work was supported by the National Institutes of Health/National Institute on Minority Health and Health Disparities Research Centers in Minority Institutions, Prostate Cancer Foundation, Georgia Clinical Translational Science Alliance KL2 Scholars Program, and Cancer Metabolism Training Program grant T32 CA221709/CA/NCI NIH.Disclaimer: The contents do not represent the views of the US Department of Veterans Affairs or the United States Government.