AORTIC 2011, Cairo, Egypt 30 November–2 December 2011

Factors influencing prostate cancer in black men

Dr Folakemi Odedina – University of Florida, Gainseville, USA

My work actually focuses on looking at prostate cancer in black men all over the world, so I take a little bit of a different approach to addressing the issue of prostate cancer by looking at the group that are genetically predisposed to prostate cancer and that is black men because one of the risk factors for prostate cancer is your ethnicity – being black. So I look at blacks all over the world, especially the ones that are connected by the transatlantic slave trade. I try to figure out whether there are any environmental differences or behavioural differences that might lead to a different burden of prostate cancer among this group so that I can develop interventions to better address prostate cancer.

What I actually presented at AORTIC, I actually have multiple presentations at AORTIC. One of the things that I did was a pre-conference workshop which took place on Tuesday. The pre-conference workshop was focussed mainly on cancer advocacy so I was able to work on a grant, I received funding from the National Cancer Institute as well as support from my institution, the University of Florida, as well as The Prostate Net. So what we essentially did, we had a one-day workshop focussed on cancer advocacy in Africa because that’s one of the things that is lagging behind as Africa moves forward in research and training relative to cancer, cancer advocacy is still not there because you really have to be able to advocate for cancer on the political level so that you can get the government to be involved in funding, on the research level so that the right research is done, on an outreach level so that you have a lot of information out in the community, on an education level and also fund-raising to be able to support. So we were able to actually fund close to fifty people that participated in the one-day workshop. From that one-day workshop we now have an African cancer advocacy consortium that’s going to help develop advocacy in Africa, in the whole continent of Africa. So that was one workshop that I focussed on.

The other two presentations, I’ve done one and I’m about to do one later on today, really focusses on the decades of research that I have done that looks at prostate cancer studies in black men in the United States, especially in Florida in the US; looking at black men in the United Kingdom, looking at black men in the Caribbean, my site is in the Bahamas, and looking at black men in West Africa. And essentially what it is is to develop a predictive model that explains prostate cancer around black men. Some of the key findings that we’ve found is, number one, we know that all black men, or most black men, are genetically predisposed to have prostate cancer. Number two, we do know that despite the fact that they are genetically predisposed, depending on the country that they reside in, you have a different burden of cancer taking place. Although I have to note that in Africa, because we do lack an effective cancer registry in Africa, we really do not know the burden of cancer in Africa but at least we were able to study differences in the behaviour of black men, differences in the behaviour of their lifestyles and what they eat. I found that, compared to the US, especially black men in Africa, they tend to eat less meat which is good, a good thing, because red meat has been linked as one of the risk factors for prostate cancer. Unfortunately we also found that they tend to report eating less fruits and vegetables, they tend to also report less physical activity; their knowledge of prostate cancer is very low, they tend to not be aware of the issues around the early detection and prevention of prostate cancer. So there’s still a lot of work that needs to be done about prostate cancer in Africa.

Then the cancer fatality seems to be a little bit higher which means that they see getting prostate cancer as a death sentence, which is something that we have to change in Africa. I think that may be linked to the fact that there are not many survivors that are coming out, that are saying, “Hey, I had prostate cancer but I’m well and good now so everything is OK.” We have a lot of that in the US, we have very strong survivor advocates and so anybody that gets prostate cancer, you can say, “Oh I know this person that had prostate cancer, they are alive and well and living good.” We really don’t have that in Africa so we do have a lot of work to do.

Are there any PSA screenings in Africa?

You know what? They have some PSA screening and even digital rectal exams, screening is going on. When you talk about PSA screening we really have to mention the fact that there is still a lot of controversy right now about PSA screening because the two major clinical studies that have been done, one that was done in the US and found that PSA screening has really not been very cost-effective when it comes to early detection of prostate cancer. But the European study does have some indication that it is cost-effective so you do have confounding evidence about that. But for me, or for my line of research, what is a little bit much more disappointing is the fact that the majority of the studies that we’ve done do not have a lot of black men involved in the study. Knowing that one of the risk factors for prostate cancer is being black, you would assume that you should have quite a critical number or a significant number of black men participating in the study for you to be able to see whether PSA screening is effective in that dataset. Regardless of the screening controversy, I think as I pointed out in one of my studies, the issue of early detection, PSA screening, I think that’s not the main issue. The main issue is two issues: number one is for us to be able to find a biological marker that can distinguish aggressive prostate cancer from what is not aggressive, number one, and number two, for us to have clinicians who really would tailor the treatment for prostate cancer to the patient instead of a broad stroking treatment to everyone. I mean, if you find that you have a baseline PSA and your PSA is rising, your clinician should be able to take a look at you and say, “You know what, it is rising but it is OK, we can do active surveillance which is actually watchful waiting. Just change your diet, change a little bit of this, and let’s see whether we can stop it from rising.” Or he can say, “You know what? At this point in time maybe I can give you something to control that, maybe it’s not prostate cancer, maybe it’s something else.” I always link it to it’s like having a headache. If I have a headache I still know I have a headache, right. I can sleep and do absolutely nothing or I can take some Tylenol or I can decide to take morphine. So what I do to address my headache could be different, it’s exactly the same way with PSA. I just don’t agree with the fact that you broadly say no screening and then you do have people who are going to end up having an aggressive form of prostate cancer, they are not detected early and they die because we are doing that.

Now, having talked about the controversy of screening, I think there’s another challenge in Africa with screening because if you go ahead and do screening and, as you know, prostate cancer detection requires PSA screening as well as doing a digital rectal exam. I think one of the struggles that we have in Africa is the fact that if you do screen people and they are found to have prostate cancer, you have to have a means of treating them. That is a struggle that we have in Africa now, if there’s no funding or resources for treatment, no appropriate way of dealing with them, then we can’t screen. You cannot get a person, tell them, “You have prostate cancer,” and tell them, “I’m sorry, you have prostate cancer, there’s nothing we can do for you but we told you you have prostate cancer, so I don’t know what is going to happen to you.” We cannot have that done. So the way we address the detection of prostate cancer in Africa has to be systematic, we have to have the resources and the manpower in place to be able to deal with it. I do have a colleague, I have several colleagues in West Africa, especially in Nigeria, and they do have population-based screening but they do make sure that they treat those people. I have a consortium in the Federal Medical Centre in Abeokuta which is in Ogun State in Nigeria and they have annual prostate cancer screening. I collaborate with them but they have mechanisms to be able to treat those who get prostate cancer in Lagos State in Nigeria too, and I’m sure most probably in South Africa. So I would not advise screening if you don’t have a means of dealing with it.