EDITORIAL: CAN WE LOWER THE MORTALITY RATE OF BLACK MEN WITH PROSTATE CANCER?

Historically, black men have the highest incidence of and mortality from prostate cancer in the world, with a mortality rate of 55.1/100,000 which is more than 2 times that of white men (24.7/100,000).1 When compared to white men, black men tend to be diagnosed with prostate cancer at a younger age, and present with higher grade tumors and metastatic disease.2, 3 In this issue of the Journal Fowler et al (page 137) compare the cancer specific mortality of 524 black and 396 white men diagnosed with prostate cancer between 1982 and 1992 at an equal access medical center (Jackson Mississippi Veterans Administration). In this hospital based series the authors found no difference in cancer specific mortality between black and white men who presented with either regional (T3‐T4) or metastatic disease. However, for clinically localized tumors (T1b‐T2), black men had a lower cancer specific survival compared to white men. After controlling for the fact that black men presented with higher grade tumors and at older ages, no difference in mortality was found between the black and white men with T1b‐T2 disease. The authors note that between 1982 and 1992 prostate specific antigen (PSA) was not in widespread use at their facility, which is reflected, in part, in the high rate of metastatic disease in black (32%) and white (16%) men in their series. In a recent series of patients diagnosed with prostate cancer in the PSA era black and white men presented with an equally low rate of metastatic disease (6% versus 4%).4 Future studies need to address if this lower rate of metastatic disease at presentation in black men will translate into decreased mortality from prostate cancer. Eastham and Kattan (page 143) reviewed their database of 257 white and 218 black men who were diagnosed with clinically localized prostate cancer between 1990 and 1998, and were treated with radical prostatectomy. When comparing baseline characteristics between the groups, the only differences were higher serum PSA levels (8.0 versus 6.1 ng./ml.) and higher PSA densities in the black patients. Analysis of the radical prostatectomy specimens showed no difference in pathological stage or grade between the groups. Furthermore, there was no difference in the rate of biochemical recurrence between the groups with a median followup of 32 months. The authors did not evaluate if a higher preoperative PSA in black men translated into higher tumor volume in the radical prostatectomy specimen as has been shown previously.5 Assuming that longer followup of the patient groups continues to show no difference in PSA recurrence, this study suggests that black men presenting with clinically localized prostate cancer in an equal access setting have similar cure rates following radical prostatectomy relative to white men despite presenting with higher PSA levels. Controversy continues regarding the ideal PSA reference ranges for black men. Age specific PSA reference ranges have been developed for black men with the upper limits of normal being higher than those for age matched white men.6, 7 However, given the increased mortality of prostate cancer in black men, it seems counterintuitive to require a higher PSA level before performing a prostate needle biopsy. Data arguing against higher PSA cutoff points for black men come from a screening study by Smith et al in which black and white men with normal digital rectal examinations underwent