1 E D I T O R I A L Finally, Good News about Prostate Carcinoma in African American Men Mack Roach III, M.D. Department of Radiation Oncology, University of California–San Francisco, San Francisco, California. I See referenced original article on pages 88 –104, this issue. Address for reprints: Mack Roach III, M.D., Department of Radiation Oncology, University of California–San Francisco, 505 Parnassus Avenue, L-75, San Francisco, CA 94143-0226. Received March 1, 1999; accepted March 9, 1999. © 1999 American Cancer Society n this issue, Myers et al. provide evidence that strategic interventions can have a positive impact on our ability to reduce the disproportionate burden of prostate cancer among African American men.1 It is well known that African American men tend to present with more advanced disease and, probably as a result of this, have a markedly lower survival rate than others in the general population. The study reported by Myers et al. contains good news. This landmark study suggests that if the appropriate resources are provided, African American men can be selectively and successfully encouraged to adhere to prostate cancer screening and follow-up. Although there is ongoing controversy about the value of screening for prostate cancer, it continues to be done widely. Recent studies demonstrate that the rate of mortality due to prostate cancer has declined recently.2 This probably reflects the first evidence of the beneficial impact of screening and early treatment. In addition to this study, the recent report by Labrie et al. from Quebec, Canada, suggest that it is possible for screening to result in a substantial reduction in prostate cancer specific mortality.3 The point is, if anybody should be screened, African American men should be, and there is evidence that screening may reduce mortality. Screening certainly results in patients’ being diagnosed at an earlier stage, which should make them “more curable.” Prospective randomized trials have demonstrated that once patients decide to have treatment, the treatment may have a significant impact on survival. For example, a study conducted by the Medical Research Council (MRC) of the United Kingdom showed that early hormone therapy resulted in a reduction in mortality due to prostate cancer and overall mortality compared with no initial treatment, but only in patients who had nonmetastatic prostate cancer.4 An additional study by Bolla et al. showed that if patients with advanced disease were given hormone therapy plus radiation, they had better survival than patients given radiation therapy alone.5 Both of these studies made the point that people can no longer argue that “no treatment has been shown to prolong survival from prostate cancer,” but in fact early intervention for men with a significant tumor burden does result in prolonged survival. An additional point is that those patients who have undergone treatment have had a good quality of life when formal quality of life studies have been conducted. 2 CANCER July 1, 1999 / Volume 86 / Number 1 In the report by Myers et al. there are a number of findings that need to be acknowledged and made known the public. First of all, among the 548 men available for the telephone survey, 75% completed the survey and consented to participate, and only 10% refused. This finding reinforces the fact that African American men are likely to participate in clinical trials and are interested in being treated appropriately. This study also shows that the intervention (in this case, calling the patient, which is a common practice in private doctors’ offices), has an impact. Calling the patient makes the patient believe that we do care, and African American men, like others, are responsive to this type of signal. A third finding is that 71% of the participants were age 50 years or older and more than 50% of the men had had less than 12 years of formal education. Despite these facts, the patients still complied. They were still interested in participating, so being elderly and being less educated does not mean that individuals, in this case African Americans, are not likely to participate. A fourth finding of this study was that only 14% thought they were at increased risk and only 19% were worried. This demonstrates a lack of awareness. However, 86% indicated that they wanted to know if they had prostate cancer. This suggests that we (physicians) may be overly paternalistic in assuming that it is better if people don’t know that they have prostate cancer. Our bias against screening should not be forced on patients. If a patient believes that he would like to know, he should be given the opportunity to know. One in five patients believe that early detection could cause health problems. This reflects some degree of awareness of the potential pros and cons associated with screening and treatment. Based on a multivariate analysis, the most important findings of this study were that men who 1) were age 50 years or older, 2) were married, 3) believed that early detection should be done in the absence of symptoms, or 4) reported an intention to have an early detection examination were likely to undergo the appropriate screening. In addition, the single most important predictor of the likelihood of undergoing early detection was being a member of the enhanced intervention group. This had an impact. It highlights the fact that if we want to reduce the excess mortality among African American men we now know how. We know that enhanced intervention has the potential to save lives and reduce mortality from prostate cancer in this high risk population. We believe these men are as likely to benefit from treatment as anyone else.6 Myers et al. are to be applauded for this classic demonstration. Hopefully, society will not ignore their important observations and will make certain that the appropriate resources are applied to reduce our excess mortality rate. REFERENCES 1. 2. 3. 4. 5. 6. Myers RE, Chodak GW, Wolf TA, Burgh DY, McGrory GT, Marcus SM, et al. Adherence by African American men to prostate cancer education and early detection. Cancer 1999; 86:88 –104, 1999. Brawley OW. Prostate carcinoma incidence and patient mortality. Cancer 1997;80:1857– 63. Labrie F, Dupont A, Candas B, et al. Decrease of prostate cancer death by screening: first data from the Quebec prospective and randomized trial. Proc ASCO 1998;17:2a. MRC. Immediate versus deferred treatment for advanced prostatic cancer: initial results of the Medical Research Council trial. Br J Urol 1997;79:235– 46. Bolla M, Gonzalez D, Warde P, et al. 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