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As racial disparities persist regarding prostate cancer, relationships between patients and providers, as well as patient education and self-care, can be crucial factors in improving outcomes, experts said.

Black men are 60% more likely than White men to receive a diagnosis of prostate cancer in their lifetime, and more than twice as likely to die from prostate cancer than White men, noted Dr. Daniel J. George, Eleanor Easley Distinguished Professor in the School of Medicine at Duke University.

“There's a biological reason that this disease is happening more frequently and progressing more aggressively, and then there's also a social access construct that's affecting how they're cared for that also influences their outcomes,” said George.

George was the co-author of a literature review published in 2022 in the journal 

 which analyzed data regarding racial disparities in prostate cancer.

“Racial disparities observed among Black men with [prostate cancer] are multifaceted, evolving from institutional racism,” George and his colleagues wrote. “Cultural factors include generalized mistrust of the health care system, poor physician-patient communication, lack of information on [prostate cancer] and treatment options, fear of [prostate cancer] diagnosis, and perceived societal stigma of the disease. In the United States, geographic trends in racial disparities have been observed. Economic factors, e.g., cost of care, recovery time and cancer debt, play an important role in racial disparities observed in [prostate cancer] treatment and outcomes.”

Acknowledging that “there is a historical perspective to just be sensitive to for Black men and women in this country that have historically been underserved by our systems for decades,” George stressed the importance of patient/provider relationships — something which his research noted “must be improved.”

“Trust is something that we're all very familiar with in life, and it comes with experience … but with medicine, sometimes we don't have that luxury,” said George. “Patients present with disease that needs to be treated — sometimes with pretty radical treatment — right from the start. For people to put their faith into the person or the system that is going to perform that radical therapy, there 

. So, building that is so critical, and recognizing that there is a divide by our cultural races that we have to be at least cognizant of and intentional in addressing, the sensitivity around [that], is really important.”

Despite persistent obstacles and disparities, George noted that there is still “a lot that’s in our control,” starting with lifestyle choices for patients.

“Prostate cancer is a chronic disease, so recognizing the other health strategies that will absolutely affect your treatment outcome, both in terms of your tolerance of treatment, your response to treatment, and your long-term recovery from treatment. It's really important for you to understand what you can modify, to maximize your outcome, to get the best result you can have,” George said. “Those are things like your exercise, your diet, your sleep. We tend to ignore that, but they’re really important aspects.”

“Having regimens associated with your lifestyle … is so important because the treatments we give will modify your motivation. It'll be harder to diet and exercise and sleep. Because the treatments are going to interfere with those things, having a structure and regimen that make them consistent will help you push against those changes that therapy is likely to cause. … It's not simply prescribing a drug or doing a surgery or radiation, it's helping patients manage themselves and in own their health care as much as we do with them.”

Patients, George said, can also empower themselves with knowledge of their disease.

“The power to understand what is happening to your body gives you the ability to manage that and manage that psychologically, but also physically,” he said. “So, understanding your particular cancer … because it's different from the people you may know who have had prostate cancer, every case is not identical, and so recognizing and understanding where you fall in that continuum is really important.”

“Education is key for patients,” said Dr. Hiba Khan, a medical oncologist and assistant professor in the clinical research division of the Fred Hutchinson Cancer Center in Seattle. “There are lots of resources out there for patients to educate themselves about not only their risk for prostate cancer but once they are diagnosed with prostate cancer, different treatment modalities that are available, different tests that they could get that could further inform risk and treatment options.”

Resources, Khan said, are available via organizations such as the American Cancer Society and ZERO Prostate Cancer. Patients, once educated, should feel comfortable and open to speaking with their providers about what they’re learning and continue to advocate for themselves.

In turn, Khan said that patients can then engage in advocacy at a community level.

“Patients should feel free to talk with their family and their friends about their diagnosis of prostate cancer,” she said. “Sometimes I know that that's a difficult conversation to have, but raising awareness in Black communities and other underrepresented communities can only raise awareness, and that maybe ensures that other people will think about prostate cancer screening earlier or think about potentially talking with their providers about that.”

Additionally, it was noted that patients can also explore the possibility of helping to make enrollment in clinical trials more equitable.

“Racial diversity is often lacking in genomic and precision medicine studies,” George and his fellow researchers wrote. “Black men are largely underrepresented in key phase 3 [prostate cancer] trials and may be less willing to enroll in clinical trials due to lack of awareness, lack of diversity in clinical trial research teams and bias of health care providers to recommend clinical research.”
“Equitable representation in clinical trials is a huge area where we, as a prostate cancer research community need to improve and we need to partner with patients in order to improve representation,” said Khan

Patients, Khan advised, should ask their providers if there is a clinical trial they may be eligible for if they are interested.

“I think this is key — getting equitable, diverse enrollment in clinical trials because it informs the next treatment guidelines. We get more information about treatments that perhaps work differently in different populations, we're less able to generalize our clinical trial findings if we don't have a diverse enrollment of populations, so improving this is really key to overall improving outcomes.”

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Patient/provider trust, education and lifestyle choices are crucial as Black men face higher incidence and mortality in prostate cancer, experts said.

What Patients Can Do as Racial Disparities Persist in Prostate Cancer

When treating patients with prostate cancer, controlling testosterone levels in the body is key, as one expert explained.

“Testosterone is the fuel for prostate cancer cells – it's what gives the cancer the signals to grow and spread and do the things that cancers do,” explained Dr. Atish Choudhury, a genitourinary medical oncologist and the chair of the Gelb Center for Translational Research at Dana-Farber Cancer Institute in Boston. “So, lowering the level of testosterone in the body is the primary way that we treat prostate cancer because that then deprives the cancer of its fuel, and starts the process of killing cancer and putting some of the cancer cells to sleep as well.”

Doctors, Choudhury explained, give patients drugs to lower testosterone in conjunction with radiation treatments.

“There have been multiple clinical trials that have shown that it basically makes the radiation more effective at killing the cancer more completely than if the testosterone stays at its normal levels,” he said.

However, Choudhury acknowledged that “castration,” is a loaded term, used in this context to refer to the chemical lowering of a patient’s testosterone.

“Castration is a very unfortunate term that is used to describe the process of lowering levels of testosterone in the body, and it's been associated with actual surgical castration, which was a treatment that we used for prostate cancer previously, where you actually remove a man's testes and decrease the level of testosterone in that way. That was actually a very effective way to treat advanced prostate cancers,” Choudhury said. “Here, we're using hormone mimics or hormone blockers to lower the level of testosterone in the body.

“And so, it can certainly have many of the same sorts of side effects as what a surgical castration might in terms of the hormonal changes, but here those side effects are intended to be quite temporary, to make the radiation work as well as possible. And then we would then allow the testosterone to recover back to normal levels, and then the side effects should eventually then wear off.”

Those side effects, Choudhury said, include an expected reduction in both sexual interest and sexual function as the testosterone is lowered — although, as he noted, occasional patients still retain some libido and are able to achieve erections while their testosterone levels are low.

“The other side effects are very similar to what women might go through during menopause, which is a sudden hormonal change in them – so can certainly lead to things like fatigue, hot flashes, moodiness and achiness.

“But some of the concerning symptoms with long-term low testosterone is it can lead to weight gain, it can lead to metabolic changes, like increasing blood sugar and blood cholesterol, decreasing muscle mass and decreasing bone mass. That's why it's very important that after the treatment is done, we want the testosterone to recover back to the normal range, so people are not having to deal with those sorts of long-term side effects.”

These treatments and their accompanying unfortunate side effects, Choudhury explained, are in the interest of patients’ long-term quality of life.

“There is a trade-off when we use hormonal treatments with radiation to make it work as well as possible and lead to side effects that are going to worsen short-term quality of life,” he said. “It's all with the intention of decreasing the risk of a recurrence that can lead to bigger quality of life issues down the line. So, we have to think about quality of life in the short term, but also over the course of the patient's remaining life expectancy.”

An expert explains the necessity of managing patients’ testosterone levels while treating prostate cancer.

Castration ‘An Unfortunate Term’ for Key Part of Prostate Cancer Treatment

Managing and mitigating long-term side effects in prostate cancer survivors are “really important,” as it affects quality of life, an expert said.

Managing Long-Term Side Effects in Prostate Cancer ‘Really Important’

After prostate cancer, it’s also important to think about possible long-term side effects and potential ways to mitigate them. Some long-term side effects of prostate cancer may include urinary incontinence and erectile dysfunction.

According to the Cleveland Clinic, urinary incontinence is the loss of bladder control, which may occur after surgery for prostate cancer, and is typically temporary in approximately 6% to 8% of patients who underwent surgery to remove their prostates.

Find the ‘Goldilocks’ of Prostate Cancer Treatment or Surveillance

“This is nothing to be ashamed of,” Dr. Stephanie Berg told CURE®, regarding patients and survivors talking about prostate cancer and screening. “If you have prostate cancer, just talk to your friends, [tell them] that you were diagnosed with it [and] make sure they are screened properly."

Berg is a medical oncologist at Dana-Farber Cancer Institute’s Lank Center of Genitourinary Oncology.

She noted that long-term side effects impact survivors’ quality of life, which is why it is important for survivors to speak with their urologists and medical oncologists about ways to effectively mitigate these side effects via devices and surgeries.

CURE® spoke with Berg about the importance of managing long-term side effects and how survivors may overcome symptoms after treatment.

Here, especially at Dana-Farber, and a lot of our bigger cancer centers is about survivorship. And survivorship is something where you’re managing incontinence, which is when you leak urine or have trouble going to the bathroom after surgery, or even radiation, which is really important because that's quality of life.

There are a lot more urologists [who], since they specialize in the urinary system, can dedicate their practices to helping men overcome this, whether it be with medications that are available, or surgical techniques to actually help whatever caused the thing in the first place.

I find it really interesting. I know, at Brigham and Women's Hospital, we have two dedicated urologists that really focus on post-procedurectomy, urinary problems for men, it's the fact that it can be so common for someone to do that. It's worth mentioning that we can help you. And the same with erectile dysfunction. I mean, other than just medication, there are other surgical techniques and even devices that can be discussed with your urologist and your medical oncologists to help overcome those types of symptoms after surgery or radiation therapy. So an important part of cancer care is that care afterwards to maintain you living as long as possible.

Transcript was edited for clarity and conciseness.

For patients who recently received a diagnosis of prostate cancer, discussing the next steps with a provider is important, especially when considering whether treatment or active surveillance is appropriate, an expert told CURE®.

According to the American Cancer Society, active surveillance is when doctors monitor the cancer closely through tests. Specifically, prostate-specific antigen levels are tested every six months from blood draws, and a digital rectal exam occurs once a year. At the same time, the doctor will create a treatment plan if the tests show a rapid change or growth in the cancer.

Dr. Stephanie Berg, medical oncologist at Dana-Farber’s Lank Center of Genitourinary Oncology, spoke with CURE® about how it is decided whether patients undergo active surveillance or receive treatment, the importance of genetic testing and advice for patients with prostate cancer.

CURE®: How is it decided which treatment is best for patients with prostate cancer?

At Dana-Farber, we have a multidisciplinary team, and we find it extremely important to have different opinions about care. So, being from medical oncology, radiation oncology and surgical oncology, talking about the different pros and cons of each approach and asking, “Is treatment needed at this time for your prostate cancer?” One of the ways that we discuss a form of treatment is actually not really a treatment at all, but something called active surveillance, where we routinely do blood tests, take pictures of the prostate and the organs — like the bladder and the lymph nodes — in the pelvis, and either biopsy and perhaps not treat patients’ prostate cancer right now, but maybe years down the road, or get treatment recommendations soon and start medical therapy.

So we really want to give patients all the pros and cons. If patients don't have that at their center, I would say it's always great to look out for someone like me like a medical oncologist, which there are a lot of us in the United States … to get more of a medical opinion, because we really serve as a liaison amongst the surgeons and radiation oncologists of knowing which modality might be best for you. Since we are trained as medicine doctors, being primary care doctors is kind of our background. In medicine, we are primary care in the beginning. So that's the hat that we like to wear.

‘Paths’ of Treatment Possibilities in Prostate Cancer

How do doctors determine whether patients should receive treatment or undergo active surveillance?

Thankfully, we have some nice guidelines that have been discussed amongst the National Cancer Comprehensive Network and the American Cancer Society, the Association of Surgical Oncology, and the Prostate Cancer Foundation, to name a few, where we're saying, “Which [patient] will benefit from treatment? Or which [patient] can perhaps wait?”

[Regarding] active surveillance, there have been large trials saying that this is an extremely necessary type of treatment option, where serial blood testing, coming to the doctor,— usually the urologist— to just keep track of the cancer [is done].

Knowing the chances of death from this diagnosis of cancer, is really important, because “cancer” is obviously a word that nobody likes to hear. But it is important to discuss with your provider, whether the treatment could perhaps be more harmful to me in the beginning versus close monitoring. This has really changed in the last 10 years in prostate cancer medicine, recognizing the fact that many men were over-treated, perhaps some are under-treated and kind of finding that Goldilocks type of in-between amongst all of us. That’s why multi-[clinician]-deep care with different opinions is really, really important.

What is the role of genetics in prostate cancer?

It’s huge. It's something where family history of any cancer is very important for every man to know, from their dad, brother, uncle and grandfather.

We know that national guidelines are recommended for men with high-risk prostate cancer, we determine different categories of risk based on certain characteristics and your doctor will tell you what [risk level] you are. If you know you have that family history, tell your team, because getting a genetic test where it could have been inherited from your mom or your dad, can result in upwards of 10% or more prostate cancers — we're discovering more every day.

Also, see a genetic counselor. I think that’s the most important part: if you do get a genetic test, somebody has to explain it to you. We value that you see a professional genetic counselor, and get your testing done in a secure format through your medical team. Have someone explain what the results mean. If a physician recommends you get it and tell them your history, that's something I always want to emphasize because that's just important. It's just good medicine to practice that we want to tell our patients.

What advice would you offer to patients with prostate cancer?

If you have prostate cancer, talk to your friends. Tell them that you were diagnosed with it and make sure that they are screened properly — to go see their primary care doctors. A lot of times we see men who have their PSAs or symptoms too late, and they just don't want to talk about it or bring it up.

It’s important to get that first round of care going in because it is the most common cancer that is diagnosed in the United States. And to emphasize, it is nothing to be ashamed of or something you shouldn’t talk about, but just get screened. Talk about it, go see your doctor, and then once it is treatable, we have so many different modalities now to really tailor each treatment to each patient, which is why we talk about the surveillance part, the surgery, the radiation part for localized disease, so we can really get a handle on it early versus later stages.

This transcription was edited for clarity and conciseness.

There are risks of patients with prostate cancer being over- and under-treated, which is why speaking to a team of doctors is important, an expert said.

An expert spoke with CURE® about the next steps for patients recently diagnosed with prostate cancer and the types of treatments they may receive.

For patients with prostate cancer, it’s important to know the next steps in terms of possible treatment that can be received, which is why CURE® spoke with Dr. Stephanie Berg, a medical oncologist at Dana-Farber’s Lank Center of Genitourinary Oncology, about the “paths” of treatment patients could take.

This is particularly important considering how common prostate cancer is. In a lifetime, approximately one in 8 men will receive a diagnosis of prostate cancer, although the risk factors may vary based on age, race/ethnicity, among other factors, according to the American Cancer Society.

When a urologist reports that a prostate-specific antigen test is abnormal, Berg noted that patients will either receive a biopsy via a needle to help determine potential treatment options or will undergo active surveillance. This means patients may not receive treatment immediately but will be closely monitored through routine blood tests, imaging of the prostate, bladder and lymph nodes within the pelvis, and biopsies.

Plant-Based Diet May Boost Quality of Life After Prostate Cancer

When you get the PSA test and determine that it's abnormal, you should go for a prostate cancer evaluation. Typically, the urologist who is a doctor [who specializes] in the male and female genital urinary systems, will recommend a biopsy and there's obviously different types of biopsy that one can get, usually something that's either guided by an ultrasound or MRI, which is actually more common [and] what we do here at the [Dana-]Farber. And it's also about surveillance, too, because perhaps a biopsy isn't needed right now or there are other things that could preclude you from getting a biopsy.

So once you have a diagnosis of prostate cancer, which is only done by needle biopsy of the prostate, which is through the perineum approach, or through trans rectally of taking samples of the prostate again at the base of the bladder where the prostate is located, your doctor, usually again, the urologist, will go over either surgery, removal of the prostate or refer you to a specialist called a radiation oncologist and someone like myself, a medical oncologist, to discuss [whether] the prostate will stay inside but using external radiation therapy or internal radiation type treatments, and medication treatments that I would provide or the radiation oncologist would provide called androgen deprivation therapy, which is lowering your testosterone level to help treat your prostate cancer. So, there are two different paths one can go down in the beginning if the prostate cancer is in the prostate.

Prostate-specific antigen (PSA) levels can be among the key factors for patients with prostate cancer to be mindful of following treatment, one expert explained to CURE®.

PSA, a protein which is associated with the presence of prostate cancer in the body, is one of factors recently identified by researchers as potentially indicative of which patients with prostate cancer are at high risk for a shorter time until prostate-specific antigen recurrence and failure.

A secondary analysis of a phase 3 clinical trial, results of which were published in 

found that among patients with nonmetastatic, unfavorable-risk prostate cancer, those who were younger than 70 years old and had a PSA level of 10 ng/mL, as well as a Gleason score (which grades prostate cancer based on a pathologist’s review of a biopsy or surgical specimen on a scale of 2 to 10) of 8 or higher had a 43.8% risk of PSA failure at three years.

Study co-author Dr. Mutlay Sayan, an instructor at Harvard Medical School and radiation oncologist at Brigham and Women’s Hospital and Dana-Farber Cancer Institute in Boston, spoke with CURE® about the importance of monitoring PSA levels, which he advised should be tested at least every six months, following completion of treatment.

“What we know is, the shorter the time to recurrence following a treatment in this group of patients, they (more that patients) tend to have not good clinical outcomes,” Sayan said.

Visits with a patient’s provider will include testing of PSA levels within a few months following treatment, according to the website of the American Cancer Society. While the ACS notes that the frequency of follow-up visits and testing may depend on the stage of a patient’s cancer and its chances of recurrence, most doctors will recommend PSA levels be tested approximately every six months for the first five years after treatment, then at least annually after that.

Testing of PSA levels, Sayan noted, are relatively simple from the patient’s perspective.

“It's just a quick blood draw in an office,” he said. “It's just one needle on your arm and collecting blood. And that's as simple as that is. And it's the best way to monitor (PSA levels) following the definitive treatment.

The best way to monitor after a definite of treatment is to check the PSA level. When the PSA level is reaching a certain point that the patient will be determined to have a biochemical failure, the failure due to PSA rising. That is an indication, perhaps, that the clinical outcome will be worse, and more so in the patient that has a shorter interval time following their definitive treatment. That information itself is important, (because) that can tell us which group of patients that we can do at an early intervention (for). Or (it tells us) before they get their treatment, that we can do a treatment escalation. Those are questions that need to be answered with a (well) designed clinical trial.

Checking PSA levels following treatment is crucial among patients with nonmetastatic, unfavorable risk prostate cancer, according to the co-author of a recent study.

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