If you are a man of African ancestry, prostate cancer needs to be on your radar. This is because, of all the men in the world, you are in the group that prostate cancer hits the hardest. Prostate cancer is different in you than it is in other men. It can be more serious.
This is not fear-mongering; it’s the truth: You are not only more likely to be diagnosed with prostate cancer, but also to have a more aggressive form that needs to be treated. You are more than twice as likely to die of prostate cancer as a man of a different heritage. So if you are a man of African descent and you are diagnosed with prostate cancer, you will more likely need to go after it with curative treatment – surgery or radiation. Active surveillance may not be the best option for you. And you need to get a baseline PSA and prostate exam starting at age 40.
“African-American men have a one-third higher chance of having more aggressive cancer than the biopsy suggests,” says Edward Schaeffer, M.D., Ph.D., Chairman of Urology at Northwestern University. This means that if you are diagnosed with cancer and have surgery to remove it, when the pathologist looks at the cancer under the microscope, it very well might turn out to be of a higher grade, or there may be more of it than expected. More worrisome: “when these men need surgery, they are more likely to need additional adjuvant treatment, or to experience a recurrence of cancer, compared to Caucasian men. Biologically, their cancers are different.” Schaeffer is a pioneer in this area and what he has learned, and is actively continuing to study, may save your life.
One of the reasons why Schaeffer’s work is so groundbreaking: He noticed differences in the cancers of his patients who were African-American or Caucasian; then he began to look specifically at prostate cancer in black men to figure out why this might be. “Almost everything that we understand about prostate cancer is based on data from Caucasians,” he says. “Our understanding of the presentation, natural history and biology of prostate cancer is based predominantly on research done on the cancer of Caucasian men.” Many of the assumptions that scientists made about prostate cancer – and even some of the markers developed to test for prostate cancer – don’t hold up in black men.
To begin to unravel this important problem, Schaeffer teamed up with PCF young investigator Kosj Yammoah, M.D., Ph.D., from the Moffit Cancer Center. “We both knew there are a lot of unknowns about prostate cancer biomarkers in men of African ancestry,” says Schaeffer. “We decided to look to see how 20 different established molecular markers for prostate cancer “performed in African-American men compared to Caucasian men. Surprisingly, we found that only about one-third of them were the same between whites and blacks.”
But in a striking development, “we also found that about one-third of these markers behaved in inverse fashion in black men compared to Caucasians.” This means that a marker that goes up in white men to signal cancer actually goes down in men of African ancestry when cancer or aggressive cancer is present. “In men of African ancestry, a lot of established biomarkers are not the same as the established markers in Caucasians.”
“The clinical implications for the behaviors of biomarkers and how they differ are unknown. We can certainly extrapolate that how we follow cancer in white patients may not be the best way to do it in men of African ancestry.”
One important thing you can do: Take Vitamin D. “African-Americans are very often Vitamin D deficient,” says Schaeffer. “Their body does not absorb that UVB radiation.” And this is important, because “Vitamin D is like a fire retardant,” explains oncologist Jonathan Simons, M.D., President and CEO of the Prostate Cancer Foundation. “It has an optimum protect effect against cancer, and it’s really important in men between their 20s and 40s – because in the absence of fire retardant, more embers can get lit. Cancer can start more easily.”
Vitamin D “is a hormone but we call it a vitamin,” Simons adds. It has a powerful anti-tumor effect. In laboratory studies, vitamin D has been shown to slow down the growth of cancer cells; it also makes them less aggressive. In people, most vitamin D – 90 percent of it – comes from exposure to the sun. When the sun’s rays hit our skin, vitamin D converts into an active form (called 1,25 dihydroxyvitamin D) that helps keep cells healthy and protects against cancer.
A simple blood test can help here, says Schaeffer. “If you check the levels of vitamin D in the blood, having a lower vitamin D level is a predictor of having a positive or negative biopsy. If a man of African ancestry has a lower vitamin D level, the chances of having a cancer detected on biopsy are even higher.” Schaeffer recommends having your vitamin D levels checked by your primary care doctor. “Your vitamin D levels have a big impact on a lot of things, including bone health, risk of heart disease and stroke — and being diagnosed with prostate cancer.’’ How much should you take? About 2,000 IU (International Units) daily is probably enough, but if your levels are low, your doctor may recommend a higher dose.
What You Should Know
There are several sneaky ways in which prostate cancer is different in black men than it is in white men. Here are the two biggest distinctions:
PSA: In men of European descent, the way PSA works is pretty well understood: A certain PSA number correlates with a certain risk of having a cancer; scientists have plotted it out – think of street signs on a map. But new research suggests that those road signs aren’t always the same in men of African descent.
“The dynamics of the PSA test and other biomarkers for prostate cancer have not been well worked out in men of African Ancestry,” says Schaeffer. “This is an area where are studies are lacking.”
“Our work has shown that prostate cancers in black men can make less PSA per gram of cancer compared to prostate cancers in Caucasian men.”
Currently, the ideal values for a “safe PSA” in an African-American man are not well established. Even more troubling: “Some of the most aggressive prostate cancers never produce PSA at a high level,” he adds.
Note: That’s why it is important to get regular prostate exams in addition to PSA tests. About 20 percent of prostate cancers are diagnosed by a rectal exam, and not by any noticeable level of PSA. (This is similar to why women need regular mammograms in addition to breast exams; some cancers don’t show up on the scan, but they can be felt.) So if you are a black man, Schaeffer advises, “it is important to understand your numbers, and to partner with a urologist who appreciates that your PSA score needs special attention.”
Tumor location: You’re of African ancestry, and your doctor suspects you may have prostate cancer. You get a biopsy, and nothing is found. Are you home free? Maybe, maybe not. “When men of African descent get a biopsy, their cancer can be missed because it can hide in the region of the prostate that is hardest to reach with a biopsy needle.” Schaeffer tells his patients to imagine the prostate as a house. The biopsy comes in underneath the basement – through the rectum, which sits just below the prostate. “In most Caucasians, tumors occur in the basement. If you are directly underneath that area, you can get a good sampling with the biopsy needles and you’re more likely to pick up a cancer. But in men of African ancestry, “there’s a higher chance that the tumor will be in the attic of the house – what we call an anterior tumor.” It is easy to miss a tumor in this out-of-the-way spot with the needle in a standard biopsy.
To be extra cautious, Schaeffer gets MRI images of his patients who are at highest risk of prostate cancer – men with a strong family history, and African-American men – and does an MRI-guided biopsy. Most biopsies are directed by transrectal ultrasound, but MRI is able to help spot cancers that are hiding in the “nooks and crannies” of the prostate.