“It might seem racist to say that cancer is different in Black men than it is in other men,” says PCF-funded physician-scientist Kosj Yamoah, M.D., Ph.D., radiation oncologist and cancer epidemiologist at Moffitt Cancer Center in Tampa, Florida. “But that couldn’t be further from the truth: it’s not about race. It’s about subtypes of cancer. It is incorrect to say that you have a different type of cancer because of your skin color; the message is that, in order to treat all men equitably, we have to study all populations.”
What are subtypes? They are specific varieties of a disease – based on differences in mutated genes, or differences in the immune system, or maybe even differences in the microbiome. Each subtype may respond slightly differently to treatments and also to biomarker tests. “We know that the cookie-cutter approach, treating all patients the same, does not work with prostate cancer,” says Yamoah. “So, we need to fine-tune our diagnosis and treatment.” Unfortunately, much of what scientists have learned about prostate cancer has come from studying predominantly white patient populations. “We have not had enough African American participation in studies and in scientific exploration.”
How can you help change this? “Get involved in research. Become active participants in discoveries for treating prostate cancer.” Particularly, different biomarkers may work better in Black men. “Whether it’s helping to determine the polygenic risk score – are you at risk, or do you have a family member at risk – or whether it’s helping to find out through biomarker discovery what subtype of prostate cancer you have, and how best to treat that, we could really use your help.” Many academic medical centers have “biobanks,” collections of patients’ blood, biopsy and tissue samples that can be used for research. If your doctor asks you to participate, consider saying yes.
Consider the case of Ashkenazi Jewish women, descendants of a very small group of about 350 people who lived in Eastern Europe about 700 years ago. Around one in 40 people with Ashkenazi Jewish ancestry has a mutation in the BRCA gene, which is linked to breast and ovarian cancer, and also other cancers, including prostate cancer. “Through studying a sub-population, we discovered that gene,” says Yamoah. But the implications of this gene are widespread: “Recently, BRCA mutations have been linked to triple-negative breast cancer, which is more predominant among African women. If we hadn’t studied it in the Ashkenazi population, we never would have identified it. Now it has become a biomarker,” and scientists have identified a class of drugs – PARP inhibitors – that work well in cancers with this genetic mutation, including prostate cancer. “It is no different from studying Black men. What we learn from identifying subtypes is going to benefit the globe.”
“It is true that systemic racism is a major cause for why many Black men die of prostate cancer,” says Yamoah, “and this needs to be addressed if we are going to fully eliminate the disparities in health outcomes in minority populations, regardless of the type of disease. That said, he adds, “it’s also very important to realize that each of us has a certain predisposition to disease. For example, some people smoke for 30 years and never get lung cancer. Others smoke for 10 years and get it. We all have a different threshold, based on our genetic predisposition.” Prostate cancer develops because a gene is mutated, “regardless of how it occurred,” whether through decades of eating a bad diet (environmental factors), or through inheriting a bad gene (direct genetic predisposition), or just bad luck.
“Some scientists might get put off by discussing biology when talking about prostate cancer disparities, warning that this might ascribe fault to the black skin for poor outcomes in prostate cancer. This is a real issue that must upset all of us who care about the problem. Patient advocates are beginning to caution against this misrepresentation, because it could result in a disguised form of discrimination, that patients are being judged based on the color of their skin,” says Yamoah. “The message is not treating you different; it’s treating you right.”
The idea of “one size fits all” medicine sounds nice and egalitarian, but in reality, one size does not fit all. Take, for example, tattoos used in radiation oncology to help pinpoint the areas of treatment. “We had some patients come through, and the technicians called me into the clinic and said, ‘We can’t find the spot; we can’t tell where the tattoo is.’ I said, ‘That’s because the ink in these localization tattoos was developed for the lighter skin and not for the darker skin!” Yamoah found a company that has developed fluorescent tattoos (which show up on any skin color), to be available for his patients with dark skin. “We have made a lot of our discoveries in prostate cancer only looking at one patient population,” but that is changing. “We are now in an era of moving towards more personalized care, regardless of race.”
Another way you can help is to become an advocate. “If you are a Black man and you don’t have prostate cancer, you can still have a voice. You have a sphere of influence; use your influence to encourage others to take heed,” to get tested starting at age 40, and to get prompt treatment from the best doctors you can find. “If you’ve had prostate cancer and you’re a survivor, please be an advocate. We need your voice. Whether you have it or whether you don’t, please help change prostate cancer for this population!”