Pathways to diagnosis for Black men and White men found to have prostate cancer: the PROCESS cohort study

Abstract

Black men in England have three times the age-adjusted incidence of diagnosed prostate cancer as compared with their White counterparts. This population-based retrospective cohort study is the first UK-based investigation of whether access to diagnostic services underlies the association between race and prostate cancer. Prostate cancer was ascertained using multiple sources including hospital records. Race and factors that may influence prostate cancer diagnosis were assessed by questionnaire and hospital records review. We found that Black men were diagnosed an average of 5.1 years younger as compared with White men (Po0.001). Men of both races were comparable in their knowledge of prostate cancer, in the delays reported before presentation, and in their experience of co-morbidity and symptoms. Black men were more likely to be referred for diagnostic investigation by a hospital department (P ¼ 0.013), although general practitioners referred the large majority of men. Prostate-specific antigen levels were comparable at diagnosis, although Black men had higher levels when compared with same-age White men (Po0.001). In conclusion, we found no evidence of Black men having poorer access to diagnostic services. Differences in the run-up to diagnosis are modest and seem insufficient to explain the higher rate of prostate cancer diagnosis in Black men. Radical treatment can cure localised prostate cancer, but can lead to serious side effects, and many untreated men do not develop advanced disease (Albertsen et al, 2005). Risk factors and prognostic factors are needed to identify those men with an increased chance of developing cancer and of seeing that cancer progress, as these men have a more favourable balance of risks and benefits when undergoing screening tests and radical treatment. Black race is one of very few factors supported by convincing evidence (Gronberg, 2003). Surveillance, Epidemiology, and End Results (SEER) data from the United States indicate that Black men are 2.4 times more likely to die of prostate cancer than White men of the same age (US Cancer Statistics Working Group, 2005). In England, where prostate-specific antigen (PSA)-based screening is uncommon, the PRostate Cancer in Ethnic SubgroupS (PROCESS) study has demonstrated Black men to have 3.1 times the incidence of prostate cancer as compared with their same-age White counterparts . Black men also have a poorer prognosis than similar age White men. A meta-analysis of US data found the disease-specific case-fatality rate to be 29% higher . The higher rate of prostate cancer in Black men may arise from a genuinely higher incidence, or alternatively there may be an equal incidence of prostate cancer but a greater likelihood of diagnosis among Black men. US studies suggest that Black men have worse access to health care generally (Institute of Medicine, 2001), and may have poorer access to PSA testing in particular (Freedland and Isaacs, 2005), although a recent study has found Black men aged 40 -49 years to be subject to a higher rate of test...

Clinical presentation and initial management of Black men and White men with prostate cancer in the United Kingdom: the PROCESS cohort study

“…The Prostate Conditions in Ethnic Subgroups, a population-based retrospective cohort study, has been previously described Metcalfe et al, 2008). Cases of prostate adenocarcinoma were identified from among males residing in four study areas (namely North Bristol, South-West London, South-East London, and North-East London) during 1995-1999(Bristol) or during 1997-2001.…”

Ethnic differences in patients’ preferences for prostate cancer investigation: a vignette-based survey in primary care

“…3,4,15 The current findings are based on a vignette that presupposed entry into health care, and strictly does not extrapolate on the decision to seek health care when a man has symptoms; however, it is plausible that a lower desire for investigation may also engender a lower desire to seek help.…”

“…4,16 They fear that the disease could be terminal and that its treatment could lead to severe sexual disorders (such as erectile dysfunction, sterility, and decreased sex drive), which, in turn, may change their close relationships with their spouses. 16,17 Several (mainly US) studies have highlighted fear as a major deterrent to black males' medical helpseeking, even when experiencing lower urinary tract symptoms.…”

“…17,20 Males of both ethnicities have similar knowledge of prostate risks and symptoms, 4 although black males tend to underestimate their personal risk of the disease, 21 and are often less conversant with the PSA and rectal examination procedures, and may abstain from investigation altogether due to this. 17,20 Some black males perceive rectal examination as a threat to their masculinity and consider it an undignified test.…”

“…17,20 They are also more likely to be too embarrassed about lower urinary tract symptoms and generally less comfortable seeing their GPs compared with their white counterparts. 4,22 These factors, in addition to language or communication barriers, stigma, and socioeconomic deprivation may provide an alternative explanation to black males' reluctance for prostate cancer investigation when symptomatic.…”