African Americans face a higher rate of diagnosis and mortality from prostate cancer than white Americans, highlighting challenges in the realm of health equity.Credit: FatCamera/Getty Images
Prostate cancer is the most common non-skin cancer in men, comprising 29% of new male cancer cases, and trails only lung cancer as the second deadliest male cancer in the United States, according to the American Cancer Society’s 2023 estimates. This silent assailant, often asymptomatic at its onset, also signals a deeper societal concern — African Americans face a 70% higher rate of new prostate cancer diagnoses than white Americans, highlighting a critical area of focus in the realm of health equity.
“This disease hits the African American population harder,” says Michael Whalen, associate professor of urology at The George Washington University (GW) in Washington DC. “They have a higher incidence of diagnosis and are almost twice as likely to die from prostate cancer.”
The evolving landscape of prostate cancer treatment challenges clinicians to stay updated, mindful of not only potential side effects but also financial ramifications. The team at GW Cancer Center merges cutting-edge personalized treatment with a mission to narrow the racial gap, fostering a health-care environment where equity and innovation go hand-in-hand.
Perspective shift
Metastatic prostate cancer, the most lethal form of the disease, has seen a shift in treatment approaches. Traditionally, androgen deprivation therapy (ADT), which curbs the testosterone production fuelling the cancer, has been the primary treatment. However, the CHAARTED trial, which highlighted early chemotherapy benefits alongside ADT, and the STAMPEDE trial, which explored combinations such as surgery and radiation, have ushered in intensified systemic therapy, markedly improving survival rates (A. Isgandarov et al. Urologie 62, 369–375; 2023).
A precision-medicine approach is necessary to control and cure prostate cancer while preserving functional outcomes. At GW Cancer Center, patients are stratified not only using National Comprehensive Cancer Network guidelines, but also by incorporating tissue gene-expression profiling and germline testing. The detection of heritable gene mutations is important for advanced disease to tailor the treatment approach and increase success rates.
Whalen notes that while there is growing interest in focal therapy for localized prostate cancer, surgery is still the primary curative option for many men based on their risk category and health status. The surgery involves removing the prostate, seminal vesicles and pelvic lymph nodes. Advancements including robotic surgery have reduced risks and improved recovery times. The era of robotic surgery has also brought improvements to post-operative functional outcomes such as continence and erectile function. Enhanced magnetic-resonance imaging and a high-tech fusion biopsy platform, employing 3D imaging of the prostate, are regularly used to boost disease detection rates.
Radiation, another cornerstone, is delivered by machines such as linear accelerators. Modern techniques like intensity-modulated radiation therapy and stereotactic body radiation therapy allow precise targeting of malignant lesions, reducing damage to adjacent tissue and organs. These technologies have been vital to treating tumour deposits at many locations throughout the body.
“Another part of our multidisciplinary approach is having certified genetic counsellors,” adds Whalen. “The BRCA1 and BRCA2 genes that people associate with breast cancer are implicated in prostate cancer as well.”
Cutting-edge care for under-served communities
Fayez Estephan, assistant professor of medicine at GW, recently won a fellowship for his work leveraging human epidermal growth factor receptor 2 (HER2), a protein expressed on cancer cells, as a disease marker to advance targeted therapies and precision medicine in prostate cancer management.
“Every patient diagnosed with breast cancer is tested for the HER2 receptor,” explains Estephan. “Advanced prostate cancer is an area of need — we don’t have a lot of therapeutic markers. Now that we have better agents to target the HER2 receptor, we wanted to take another look.”
Estephan and Whalen’s work at GW Cancer Center enables patients to enrol in several cutting-edge clinical trials, often combining treatments across multiple disciplines. The ongoing Southwest Oncology Group (SWOG) 1802 trial explores the impact of definitive prostate therapies including surgery or radiation in metastatic settings, a shift from the conventional use of systematic therapy alone. The INNOVATE trial combines ADT with salvage radiation. The GW team is working to improve patients’ access to such trials, particularly those from historically under-served communities.
“About 40% of our prostate cancer patients are Black,” says Whalen. “But Black representation in clinical trials throughout this country is notoriously low. One reason for that may be potential mistrust of experimentation. We need to navigate those social barriers.”
The story of patient Y, a 63-year-old Black man currently taking part in the SWOG 1802 trial at the GW Cancer Center, underscores some of these barriers. He relates a journey familiar to many: a primary care physician unfamiliar with the critical signs of prostate cancer, where his escalating fatigue was overlooked.
“I told him I was tired climbing the staircase. But he was busy during his visits, and he couldn’t determine the clues,” says patient Y. There is frustration in his voice as he recounts the missed opportunities for an earlier diagnosis, which may have altered the course of his treatment.
Patient Y values the community-oriented approach at GW Cancer Center and the rapport he shares with the medical staff. Nonetheless, he grapples with treatment-induced regret, chiefly the loss of sexual function, a common side effect that underscores the complex journey of prostate cancer patients. Practitioners need to prioritize these quality-of-life concerns, Whalen says, rather than only focusing on quantity of life. Further investigations are needed to work towards achieving success on both fronts.
Redefining personalization
At GW, a leading academic medical centre, community is the key to providing comprehensive, personalized care for cancer patients. This ethos extends to monthly free cancer-screening clinics, dedicated patient navigators, reduced-cost pharmacies and a close-knit team that encourages frequent interaction among staff and trainees.
“Being able to champion clinical trial enrolment among under-served populations and give them world-class care, that keeps me engaged,” says Whalen. “Because it’s a teaching institute, working under the impressionable gaze of students and residents — who will in turn become the future leaders of our profession — means we have to perform at a high level.”
Estephan says engaging patients in clinical trials reflects a core belief at GW Cancer Center — achieving the best outcome requires treating both patient and disease from many angles.
“In personalized medicine, we tailor a therapeutic plan not only to treat the cancer but also to serve the patient’s social needs — what’s best for patient A might not work for patient B,” says Estephan. “Recovery from prostate cancer is trying to mediate and mitigate all these toxicities coming from the disease — the treatment, as well as the financial and social aspects. That takes a team approach, which is what we have here at GW. We’re really proud of that.”