Race and PSA Impact Mortality in Low-Risk Prostate Cancer

Gerald Chodak, MD


April 16, 2019

This transcript has been edited for clarity.

Hello. I'm Dr Gerald Chodak for Medscape. Today's commentary is based on another presentation from the recent ASCO Genitourinary Cancers Symposium in February. This was a report by Lu-Yao and coworkers, looking at prostate cancer–specific mortality for men who were managed by active surveillance after diagnosis of low-risk disease.[1]

The investigators specifically evaluated and stratified patients by PSA level at diagnosis and race—being Caucasian or African American. Low-risk disease included men with a PSA up to 10 ng/mL, a Gleason score of 2 to 6, clinical stage T1 or T2 disease, and finally, N0 and M0 disease. Patients could not be treated with surgery or radiation within 1 year of diagnosis.

The investigators looked at a number of factors and analyzed the data using the Kaplan-Meier method. The factors that impacted mortality were race and PSA level at diagnosis. When men were divided into those who had a PSA level of less than 4 ng/mL or a level between 4 and 10 ng/mL, the men with the higher PSA had a significantly higher risk of dying from prostate cancer.

Among men who had a PSA level of less than 4 ng/mL, race did not matter—Caucasians and African Americans had the same risk for prostate cancer mortality. However, for men with a PSA between 4 and 10 ng/mL, African Americans had about a 43% higher risk of dying from their disease.

Caution is needed in the interpretation of these findings for several reasons. Because it wasn't a prospective analysis, a number of factors could have impacted the higher mortality [rate observed] for African Americans.

How often were they monitored? What were the decisions or methods used to define when they should receive definitive therapy, and of course, the method of treatment that was actually selected? Those factors cannot be evaluated from this analysis.

However, if the results can be verified and there are differences based on both PSA and race, then we have to consider what to do with that information.

Is it possible that once the PSA reaches 4 ng/mL, African American men may have a different rate of rise for their PSA? The rate of rise at that point might be a factor to consider when determining whether to discontinue active surveillance. The bottom line here, however, is that for African American men whose PSA level is not higher than 4 ng/mL, they do not seem to be at a higher risk of dying of their disease.

This has been a concern because a number of studies have suggested that African Americans have a worse prognosis for their disease after considering baseline PSA levels. This information warrants further study.

For now, we can at least tell African Americans that active surveillance is safe when their PSA levels are less than 4 ng/mL. Additional studies are needed to determine whether the risk is higher in African Americans than in Caucasians when PSA levels are between 4 and 10 ng/mL.

I look forward to your comments. Thank you.


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