Whenever you go to our meetings, people talk about and they love to quote these things,
"Oh get a PSA if you're this age or if you're high risk" and another thing they always say,
"or if you're an African-American male," and then you see these arguments we have all the time
African-Americans have a higher risk from dying of the disease
and is this something going on genetically—people will argue, pathologists, urologists, radiation
oncologists—or is it is it a reflection of a health disparity that their access, in general,
is inadequate? So, where do you stand now with all these genetic studies saying well there are
these genetic variants we're seeing in some African-American men or these other camps are
saying, no it has nothing to do with that the more we look at this it's actually just all straight
health disparity that many african-american men and families don't have access to care,
so they're diagnosed late? So, where do you stand on that since I've never asked you?
Okay, so I'm gonna give you the short answer and then then the detailed answer. First,
the short answer is, garbage in garbage out." 20 years ago—actually closer to 30 years ago—I
was writing papers saying that race was not biologically responsible for differences
in outcome between black and white men with prostate cancer. All of these papers were
being published saying, "Oh prostate cancer is more aggressive in black men. Prostate cancer is
more aggressive," and I was going, "No it's not folks; no it's not folks; no it's not folks."
Now, the last time I looked at the data, there were 13—if you just take data from phase III
prospective randomized trials that have been published the last time I looked there were 13
of them—that now attempted to adjust for race, and if you adjust for race, 8 of the 13 studies,
there was no difference in outcome by race. So now you're talking about randomized—they come in, they
get the same workup, they get the same treatment, the same follow-up—race falls out. Three of them
um actually showed that African-American men did better than whites, and one of them showed that
whites did better than African-Americans. The ones that showed that African-Americans tend
to do better—and there's one actually in the press that's going to be published soon—they were larger
and more recent. So, all of a sudden the pendulum was swinging, you know, 30 years ago everybody
would say, "Oh the biology is more aggressive in African-American men; the biology is more
aggressive in African-American men," and now you got people who are saying, "Oh, the biology is
different in black people and white people and therefore, you know, black men are doing better.
Garbage in, garbage out—race is not important. What's important is quality
of treatment. First of all, you can't do anything about people's race anyway.
Race is a phenotypic system that is used to characterize people. Most biologic systems are
driven by pressures which occur early in evolution or early in life and there's not much difference
between people. Now, we do know that prostate cancer is more common in African-American men.
The area where research needs to be done is not in outcome. If you adjust for everything else,
there's nothing different in the biology, but the incidence is clearly more common, and the
question is why is it more common? Well, the most stressed people are African-American men —
high unemployment, low education, poor diet, and stress impacts the immune system.
So, if you take a kidney transplant patient and they get cancer they're more likely to, you know,
to have aggressive disease. So clearly, stress could explain it. But prostate cancer is not more aggressive in African-American men;
it is more common in African-American men, and that explains all or most of the disparity in
outcome. Quality of care is a factor, but how common it is, is a big factor.