Active Surveillance of Prostate Cancer for African-American Men: A Need for More Caution

By Gerald Chodak, MD

Published Jun 5, 2014

One of the important changes occurring in the management of early-stage prostate cancer is the increasing use of a conservative therapy called active surveillance. It means that men are not immediately treated following their diagnosis, but instead are carefully monitored and treated only if certain things happen. The reason for its growing use is the recognition that a significant percentage of newly diagnosed cases will never progress or harm the patient, making treatment unnecessary. However, if those men are treated, they run the risk of developing a worsening quality of life due to the side effects that can occur.

Although the worldwide experience with active surveillance is increasing, it is still relatively new with only limited information available beyond ten years of follow-up. The best way to summarize it is to say that it is a “work in progress.” Questions that remain include, “Who is an ideal candidate? What is the best way to follow someone? When should it be abandoned and definite treatment initiated?” Another important question is whether the criteria that are being used are applicable to all races.

Recently, a study was presented addressing the question about race. Doctors at Johns Hopkins showed their results for men on active surveillance and found that African-American men were more than twice as likely to have worsening of their cancer on a repeat biopsy when compared to Caucasian men. What does this mean? First, it means that more information is definitely needed because at present, the number of African-American men being followed with active surveillance is quite small; in this study, only 39 men out of 654 were African American, which is too small to draw any firm conclusions. Until more information becomes available, African-American men should be aware that they may need different measures to determine if they should go on this treatment and stay on it. One measure that might be used is called the PSA density or PSAD. It is determined by dividing the PSA level by the volume of the prostate. Some doctors in the United States believe that active surveillance should be used in men only if their PSAD is less than 0.15. However, in general, African-American men have larger prostate glands, which would result in their PSAD being lower than most Caucasian men. For that reason, using a PSAD of 0.15 could result in more African-American men qualifying for active surveillance, including those with a more significant cancer. Doctors will have to look carefully at the PSAD in this ethnic group to find out whether a different cutoff value should be used.

For now, active surveillance continues to evolve as a good choice for many of the men being diagnosed by a PSA level, including African Americans. However, more work is needed to be sure when it should be abandoned in favor of some form of aggressive therapy, particularly for racial groups that have not been well studied.