A R T I C L E

Prostate Cancer Screening Guidelines for

African American Veterans: A New
Perspective
Arthi Reddy, B.S., Russell Roberts, M.D., Divya Shenoy, M.D., Satyaseelan Packianathan, M.D., Ph.D.,
Shankar Giri, M.D., Srinivasan Vijayakumar, M.D.

Author affiliations: Arthi Reddy, UMMC Radiation Oncology, 2500 N State St, Jackson, MS
39216, USA; Russell Roberts, UMMC Radiation Oncology, 2500 N State St, Jackson, MS
Declarations of interest: There are no interests to declare. 39216, USA; Divya Shenoy, UMMC Radiation Oncology, 2500 N State St, Jackson, MS 39216,
USA; Satyaseelan Packianathan, UMMC Radiation Oncology, 2500 N State St, Jackson, MS
Disclosure statement for authors: 1. Ownership: No authors own or have an eq- 39216, USA; Shankar Giri, G.V. (Sonny) Montgomery VA Medical Center Radiation
uity position in a health-care-related company who product or category of Oncology, 1500 E Woodrow Wilson Ave, Jackson, MS 39216; Srinivasan Vijayakumar,
products is mentioned in the article. 2. Patents: No authors hold any patents for a UMMC Radiation Oncology, 2500 N State St, Jackson, MS 39216, USA
health-care-related product or category of products named in the article. 3.
Participation.a. No authors are paid consultants to health-care-related com- Correspondence: Srinivasan Vijayakumar, email: [email protected]
panies whose product or category of products is mentioned in the article.b. No
ª 2018 by the National Medical Association. Published by Elsevier Inc. All rights reserved.
authors have ongoing relationships (advisory board membership, research
grant, speaker’s program, etc.) with a health-care-related company whose https://doi.org/10.1016/j.jnma.2018.10.010
product or category of products is mentioned in the article.

Abstract: Background: Prostate cancer is the most common form of cancer, other
than skin cancers, in American men and the second leading cause of cancer
deaths. In 2012, the US Preventative Task Force recommended against the BACKGROUND
prostate specific antigen-based screening for prostate cancer, regardless of race

P
or age, due to overtreatment of low-risk disease and lack of impact on disease rostate cancer is the most common form of cancer,
outcomes. In African-American men, however, the incidence of prostate cancer
is almost 60% higher and the mortality rate is two- to three-times greater than that
other than skin cancers, in American men and the
of Caucasian men. In the subpopulation of African-American veterans, many second leading cause of cancer deaths.1 African-
have been exposed to chemicals that increase incidence of high-risk prostate
cancer. The yearly total number of veterans with prostate cancer based on American men have the highest incidence of prostate can-
quantification is 3471.9, and the total number of annual prostate cancer deaths is
556. Considering these facts, we examine whether or not it is appropriate to screen
cer and are more likely than Caucasian men to be diagnosed
African-American veteran males for prostate cancer. with an advanced form of prostate cancer.2 In 2016, there
Previously, we reviewed data on African-Americans in the general population. We are estimated to be 180,890 new diagnoses of prostate
concluded that new guidelines needed to be implemented for screening African-
Americans. Here we review the pertinent issues related to African-American
cancer and 26,120 deaths attributable to prostate cancer. The
veterans. rate for new cases of prostate cancer is 0.1294%, and the
Methods: We performed a PubMed and Google Scholar search using the mortality rate is 0.0207%. Age is the greatest risk factor for
keywords: African-American veteran, prostate cancer, mortality, PSA density,
molecular markers, and Agent Orange. The articles that were relevant to the prostate cancer; race is second. In African-American men,
clinical, molecular, social, and health policy aspects of the diagnosis and
treatment of prostate cancer in African-American veterans were analyzed. The
however, the incidence of prostate cancer is almost 60%
data was then summarized. higher, and the mortality rate is two- to three-times greater
Results: After surveying the literature, we found several areas where the African- than that of Caucasian men.2 Comorbidity also plays a role
American veteran population differed from their Caucasian counterparts. These
areas were incidence, clinical course, social differences, PSA levels, mortality in treatment and prevention of the disease.
rate, and molecular markers. A subset of the veteran population was also
exposed to Agent Orange, which has been shown to increase the incidence of
The Veteran’s Health Administration is an unbiased,
aggressive forms of prostate cancer. Lastly, the current USPTF guidelines race and color blind, equal and open access, single-payer,
recommending against prostate cancer screening were based on patient
cohorts containing disproportionately low numbers of African-Americans,
government-run healthcare system. The VA healthcare
limiting their extension to the African-American veteran population. system is labeled as a veteran-specific, national healthcare
Conclusion: After reviewing and summarizing the literature, we contend that a system because the Federal government owns a majority of
need exists to develop and implement more targeted prostate cancer
screening guidelines for African-American veterans. its healthcare delivery sites, employs the healthcare pro-
Abbreviations: AUA, American Urological Association; ERSPC, European
viders, and directly provides the majority of healthcare
Randomized Study of Screening for Prostate Cancer; PIVOT, Prostate cancer services to veterans.3 Any veteran eligible for VA health-
Intervention Versus Observation Trial; PLCO, Prostate, Lung, Colorectal, and Ovarian
cancer screening trial; PSA, Prostate Specific Antigen; SNP, Single Nucleotide care must meet the statutory definition of a “veteran,” meet
Polymorphism; UCLA, University of California, Los Angeles; USPSTF, US Preventative
Services Task Force; VA, Veterans Affairs; VHA, Veterans Health Administration
the statutory definition of “active duty,” and serve a min-
imum period of “active duty.” Based on the National
Keywords: Prostate cancer screening-PSA-African american-Veteran
Center for Veterans Analysis and Statistics, the projected
total veterans in 2016 is 21,368,156, of which Black

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 PROSTATE CANCER SCREENING GUIDELINES

African-American veteran
White Black Prostate Cancer
Veterans Veterans Veterans Mortality
Total 21,368,156 17,458,264 2,683,046 PSA Density
Incidence of 26,688 22,590 3471.9 Molecular Markers
Prostate
Cancer
Agent Orange
Death by 6196 3614 556
Prostate We used combinations of these words to find peer-
Cancer reviewed publications with information regarding
% Deceased 23% 16% 16% African-American veterans and prostate cancer. The arti-
with Prostate cles that were relevant to the clinical, molecular, social,
Cancer
and health policy aspects of the diagnosis, and treatment of
prostate cancer in African-American veterans were
analyzed. The data was then summarized.
veterans represent 2,683,046, the equivalent of about 8%.
The number of White veterans is estimated to be around RESULTS/DISCUSSION
17,458,264.4 The incidence and mortality rate of prostate Incidence of prostate cancer among
cancer, respectively, are 0.129% and 0.020%.5 Quantifi-
African-American veterans
cation based on the incidence and mortality rates leads to
an estimated total number of veterans with prostate cancer In the general population, African-Americans have a much
as 26,688 and the total number of veteran deaths as 6196. higher incidence of prostate cancer. Within the veteran
In the African-American population, the yearly total population, a striking difference in the incidence of pros-
number of veterans with prostate cancer based on quanti- tate cancer is apparent once again. Prostate cancer ac-
fication is 3471.9, and the total number of annual prostate counts only for 28.9% of all cancers in White veterans but
cancer deaths is 556. 42.7% of all cancers in Black veterans.4 African-American
In 2012, the US Preventive Task Force (USPTF) rec- veterans also present with a more aggressive form of
ommended against the prostate specific antigen (PSA)- the disease. Indeed, one study based on data from the
based screening for prostate cancer. The VA Health System VHA found that while 26% of White veterans pre-
has integrated electronic records, so it is possible to review sented in Stage D, the number of Black men presenting
these records at the national level. Over 80% of prostate with equivalent disease was doubled at 52%.8
cancers diagnosed in Veterans Health Administration Clinical course of prostate cancer in
(VHA) are localized to the prostate gland and only 5% are
African-American veterans
metastatic.6 This means that the majority of the patients
diagnosed are eligible for definitive treatment. Medical and Along with the higher incidence noted in the African-
professional organizations, such as the American Uro- American male population, the clinical course of prostate
logical Association (AUA), USPSTF, and VHA, have cancer in African-American men differs from that of the
published guidelines for prostate cancer screening. The Caucasian population. Early in the disease course, the
VHA does not recommend prostate cancer screening with clinical characteristics of prostate cancer in African-
PSA for men ages 45e70 but recommends that any de- American men and white men are similar, but on au-
cision to initiate or continue prostate cancer screening with topsy of men who had prostate cancer but died of unrelated
PSA for any veteran should be based on a decision be- causes, it was found that African-American men carried a
tween the patient and his provider.4 higher prostatic tumor volume and were 4-times more
Previously, we reviewed data on African Americans in the likely than white men to develop aggressive, metastatic
general population and concluded that new guidelines needed disease.9 These findings support the hypothesis that pros-
to be implemented for screening African-Americans.7 Here tate cancer in African-American men has a higher growth
we review issues related to African-American veterans. rate or transforms to more aggressive forms earlier than in
White men. Since the 5-year survival rate among men with
distant metastases is only 29.3%, it is important that
METHODS
aggressive disease is detected early in its course.10 These
We performed a PubMed and Google Scholar search using findings also explain, in part, why African-American men
the keywords: are more likely to present at a later stage than Caucasian

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PROSTATE CANCER SCREENING GUIDELINES

men of similar age. A study from the Shared Equal Access higher serum PSA levels signify an abnormality within the
Regional Cancer Hospital Registry, which covers multiple prostate gland although many factors are known to affect
VHA centers with relatively large proportions of African- PSA levels including age. The PSA levels of 752 men of a
American patients, showed that African-American men bi-racial veteran population were taken. In this specific
were more likely to experience biochemical recurrence population, the mean PSA level in men without prostate
than men from other ethnic groups. cancer was 7.97 ng/ml compared to the 4.94 ng/ml mean in
There also seem to be multiple genetic components a comparable White veteran population without prostate
contributing to the differences seen in the clinical courses cancer.19 Generally, PSA levels higher than 4 ng/ml are
of African-American men compared to Caucasian men. In associated with increased prostate cancer risk although
individuals with prostate-cancer-negative biopsies for prostate cancer is 1.4-times more likely to develop in men
example, the PSA levels of the African-American men with a PSA level greater than 2.5 ng/ml. A PSA level of
were 1.8-fold higher than those found in Caucasian men, 2.5 ng/ml is a reasonable predictor of prostate cancer
even after controlling for prostatic volume.11 Also, it has diagnosis within four years; a lower threshold of 1.9 ng/ml
been suggested that African-American men are more sus- can be used as a predictor for African-Americans.20 While
ceptible to prostate cancer because of shorter repeat African-American men tend to have higher PSA levels
lengths in comparison to Caucasians and Asians.12 Lastly, than other races, they are as likely as their White veterans
several risk-associated single nucleotide polymorphisms counterparts to get their PSA levels tested.
(SNPs) are overexpressed in African-American men,
Mortality rate
which we will discuss more in depth later.13
African-Americans, in general, are three times more likely
Social differences in the African-American
to die from prostate cancer than other races. However, the
population mortality rates for African-American and Caucasian vet-
There are several social differences within the African- erans were similar in a study conducted in 2013 at the
American population that can contribute to poorer out- Connecticut VHA System. Similarly, a team with the VA
comes relative to Caucasians and Asians. First, there is a and UCLA studied more than 1200 California veterans and
discrepancy between Caucasian and African-American found “no significant differences in tumor burden, treat-
males in insurance coverage. About 90% of Caucasian ment choice or survival for African-Americans or survival
men over 50 years of age have health insurance, but only outcomes between African-Americans and Caucasians
81% of similarlage group African-American men carry cared for in the equal-access VA health care setting.21
health insurance.14 Second, poor health seeking behaviors There was, however, a difference found in the private
in African-American men can contribute to delayed diag- sector. Five reports have documented the quantitative re-
nosis and more advanced disease at diagnosis.15 Addi- sults of the association of race and mortality among men
tionally, when compared to Caucasian men with similar with prostate cancer in equal-access systems, in which
stages of disease, African-American men are less likely to outcomes were similar for Black and White men.22
be treated.16 Delayed diagnosis coupled with lack of
USPSTF recommendation
treatment thus significantly affects the outcome of African-
American men with prostate cancer. Third, many barriers The purpose of screening for prostate cancer is to reduce
traditionally associated with lower socioeconomic status the death rate linked to prostate cancer, but it was esti-
are major contributors of poorer health outcomes.13,17 mated that screening only benefited 0e1 men out of every
Fourth, there appears to be a contribution from the pa- 1000 screened.23 In addition to having a low influence on
tient’s diet; diets high in saturated fat are associated with outcomes, there is a high rate of false-positives, which led
an increased risk of prostate cancer. In general, African- to an over diagnosis of prostate cancer in 17e50% of
American men tend to consume more saturated fat and cases.23 Despite the potential over-treatment in the general
calories per day than Caucasians and Asians.12 Whitte- population, African-American males, however, are under-
more suggests that differences in saturated fat intake could treated as a group, which contributes to increased pros-
account for approximately 10% of the Black-White dif- tate cancer mortality in this population.
ference in prostate cancer incidence.18 In 2008, the USPSTF took a two-tiered approach to
prostate cancer screening. The guidelines noted that
PSA levels are higher among African-
screening men under the age of 75 had Grade I support -
American men which meant that there was insufficient knowledge of risks
PSA is a protein antigen produced only by prostate gland to support screening. In men over 75, however, screening
cells and released into the blood. Generally speaking, was not recommended based on Grade D evidence -

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 PROSTATE CANCER SCREENING GUIDELINES

meaning there was a moderate or high risk of certainty that cancer.28,29 For instance, several studies have identified
the service had no net benefit or had an unfavorable risk/ multiple single nucleotide polymorphisms (SNPs) that are
benefit ratio.23 preferentially expressed in African-Americans. Approxi-
The current USPSTF guidelines recommend against mately 100 genes containing SNPs have been linked to an
prostate cancer screening for men of all ages, regardless of increased susceptibility to prostate cancer. Single nucleo-
race, and the recommendation is considered to be supported tide polymorphisms are especially valuable in disease
by Grade D evidence. The argument that while the lifetime detection, monitoring, and screening because they are
risk of prostate cancer is 15.9% but the risk of dying is only stable throughout the lifetime of the individual and are not
2.8%, suggests that many cases of prostate cancer have affected by external factors, such as lifestyle.29 Several
favorable outcomes, regardless of early detection or treat- studies have shown that African-American males are at
ment.24 The current guidelines, however, were based on the increased risk of prostate cancer, in part, because they
findings of two studies - the Prostate, Lung, Colorectal, and possess many of these SNPs. Xu et al. showed that 17 of
Ovarian Cancer Screening Trial (PLCO) and the European 20 SNPs are more common in African-American males,
Randomized Study of Screening for Prostate Cancer and of the 17 SNPs, 2 were associated with a higher risk of
(ERSPC). The PLCO trial noted that men in their screened prostate cancer.30 Freedman et al. showed that a 3.8MB
group had a 12% higher incidence of prostate cancer but an interval on chromosome 8q24 was associated with prostate
equal death rate.25 Finding that screened men had similar cancer and was found mainly in African-Americans.31
outcomes but had been exposed to additional pain and Families with a history of particular allelic variants
bleeding associated with screening and follow-up led the within this interval were 9.46 times more likely to develop
authors to conclude that there was no net benefit to prostate cancer than those without these variants.31
screening for prostate cancer in their population. However, In addition, several biomarkers have shown differential
the PLCO trial cohort only included w4% African- expression between aggressive and non-aggressive forms
American men, which raises questions on the ability of of prostate cancer.32 Unfortunately, these molecular find-
these results to be generalized to the African-American ings have not yet been incorporated into screening pro-
population as a whole.25 The ERSPC investigated whether tocols. In addition to increasing the accuracy and validity
PSA screening would lead to increased survival. After of screening, incorporating biomarkers would also
eleven years of follow-up, they reported that in order for 1 decrease unnecessary invasive procedures which in turn
death from prostate cancer to be prevented, an additional 37 would positively impact the net benefit of screening.33 It
cases of prostate cancer had to be first diagnosed and 1055 has also been suggested that such a screening program
individuals needed to be screened.26 Although specific de- with molecular markers could identify aggressive tumors
mographic information was not released, this study was would decrease prostate cancer morbidity and mortality.In
conducted in eight European countries which traditionally short, effective screening for prostate cancer in African-
did not house large populations of African descent, which American males will need to incorporate these molecular
again introduces uncertainty of their findings’ applicability findings into protocols that successfully identify in-
to the general African-American population. dividuals at increased risk for aggressive prostate cancer.
The Prostate Cancer Intervention Versus Observational Such updated guidelines would allow for more precise
Trial (PIVOT) is another study related to these outcome identification of aggressive and metastatic disease,
measures. This study compared expectant management of improve survival outcomes, and lower overall treatment
prostate cancer with radical prostatectomy and found no costs.
difference in outcomes between White and African-
American males.27 The comparable outcomes in this
Other considerations (Agent Orange)
study are concerning for despite these findings, African- About three million Americans served in the armed forces
American men generally have an increased prostate can- in Vietnam during the 1960s and 70s. During this time, the
cer mortality. Thus, although w one-third of PIVOT trial military used large amounts of a defoliant called Agent
participants were African-American males, the two arms Orange to eliminate forest cover. In a study conducted at
of this study may not represent the treatment choices seen Portland Medical Center and Oregon Health Sciences
in general practice or that the study may have been inad- University, it was found that veterans exposed to Agent
equately powered to detect racial differences. Orange were not only more likely to develop prostate
cancer, but also more likely to develop a more aggressive
Molecular markers form of the disease.34 Agent Orange exposure is associated
Certain molecular markers have also been linked to the with a 52% increase in the detection of prostate cancer and
clinical course and disease outcomes in men with prostate a 75% increased risk of high-grade prostate cancer.35

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL 112, NO 5, OCTOBER 2020 451
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PROSTATE CANCER SCREENING GUIDELINES

would be able to identify patients at risk of the more

Figure 1. Proposed schema for screening.
aggressive forms of prostate cancer and potentially
40-year-old AA veteran decrease prostate cancer mortality, while minimizing the
Informed consent rates of false positive tests that may previously have led to
DRE
Serum PSA unnecessary treatment of benign disease. Figure 1 below
represents a potential screening flowchart. In future re-
ports, we will investigate how comorbidities may affect
prostate cancer incidence and mortality rate. The most
Normal DRE and PSA Abnormal DRE or PSA prevalent comorbid disease with prostate cancer is car-
or PSA parameters diovascular disease. This also happens to be the number
one cause of death in the African-American population.
Investigating these links an exploiting any identifiable
links may positively impact the morbidity and mortality
associated with both these diseases.
Repeat once annually Biopsy
for 3 yearsDetermine: SNP testing
PSA density
Abnormal
REFERENCES
PSA velocity Treat as clinically
appropriate. 1. Prostate Cancer. (n.d.). Retrieved September 14, 2016, from
If normal, repeat at age http://www.cancer.org/cancer/prostatecancer/.
50.
2. Odedina, F. T., Akinremi, T. O., Chinewundoh, F., et al. (2009).
Prostate cancer disparities in Black men of African descent: a
comparative literature review of prostate cancer burden
among Black men in the United States, Caribbean, United
Kingdom, and West Africa. Infect Cancer Agent, 4(1), S2.
https://doi.org/10.1186/1750-9378-4-S1-S2.
There was, however, no increase in the risk of low-grade
prostate cancer. Men exposed to Agent Orange were also 3. Administration, V. H. (2016, September 13). Veterans Health
Administration. Retrieved September 15, 2016, from http://
diagnosed at a younger age compared to men who were
www.va.gov/health/.
not exposed to the carcinogen. In conclusion, exposure to
Agent Orange appears to potentiate the detection of 4. Planning, O. O. (2016, April 15). National Center for Veterans
prostate cancer and incidence of high-grade prostate Analysis and Statistics. Retrieved September 15, 2016, from
cancer.35 http://www.va.gov/vetdata/Veteran_Population.asp.

5. Surveillance, Epidemiology, and End Results Program. (n.d.).

Retrieved September 15, 2016, from http://seer.cancer.gov/
CONCLUSION
statfacts/html/prost.html.
There is an immense need to implement new, more tar-
6. GPRA Report on Prostate Cancer.(2009).
geted prostate cancer screening guidelines for African-
American males within the nation-wide VHA system. 7. Shenoy, D., Packianathan, S., Chen, A. M., & Vijayakumar, S.
African-American male veterans have a higher incidence (2016). Do African-American men need separate prostate
of prostate cancer and present at a higher stage than their cancer screening guidelines? BMC Urol, 16, 19.
peers. Prostate cancer in these men tends to be more 8. Brawn, P. N., Johnson, E. H., Kuhl, D. L., Riggs, M. W., & Speights,
aggressive at presentation and/or transforms to more V. O. (1993). Johnson CF Stage at presentation and survival of
aggressive forms earlier. Social factors, such as delayed white and black patients with prostate carcinoma. Cancer, 71,
diagnosis, lower rates of treatment, and dietary factors, can 2569e2573.
all contribute to worse disease outcomes. In addition, the 9. Powell, I. J., Bock, C. H., Ruterbush, J. J., & Sakr, W. (2010). Evi-
exposure of many veterans to Agent Orange has been dence supports a faster growth rate and/or earlier trans-
shown to increase the incidence of high-grade prostate formation to clinically significant prostate cancer in black than
cancer. The current USPSTF guidelines recommending in white American men, and influences racial progression and
against prostate cancer screening were based on trials that mortality disparity. J Urol, 183(5), 1792e1796.
were not fully generalizable to the African-American 10. Ries, L. A. G., Melbert, D., Krapcho, M., et al. (Eds.). (2007). SEER
population because such individuals were underrepre- Cancer Statistics Review, 1975-2004, National Cancer Institute,
sented in the investigational cohorts. In including tech- Bethesda, MD. Available at http://seer.cancer.gov/csr/1975_2
niques that detect molecular markers, future guidelines 004/. Accessed October 16, 2009.

452 VOL. 112, NO 5, OCTOBER 2020 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Downloaded for Anonymous User (n/a) at Hacettepe University from ClinicalKey.com by Elsevier on October 03,
2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
 PROSTATE CANCER SCREENING GUIDELINES

11. Henderson, R. J., Eastham, J. A., Culkin, D. J., et al. (1997). 24. SEER Cancer Statistics Review, 1975e2006. National Cancer
Prostate specific antigen (PSA) and PSA density: racial differ- Institute Web site.(2009). http://seer.cancer.gov/archive/csr/1
ences in men without prostate cancer. J Natl Cancer Inst, 975_2006/. Accessed June 1, 2015.
89(2), 134e138.
25. Andriole, G. L., Crawford, E. D., Grubb, R. L., 3rd, et al. (2012).
12. McIntosh, H. (1997). Why do african-american men suffer more Prostate cancer screening in the randomized prostate, Lung,
prostate cancer? J Natl Cancer Inst, 89(3), 188e189. colorectal, and ovarian cancer screening trial: mortality results
after 13 years of follow-up. J Natl Cancer Inst, 104(2), 125e132.
13. Du, X. L., Fang, S., Coker, A. L., et al. (2006). Racial disparity and
socioeconomic status in association with survival in older men 26. Schröder, F. H., Hugosson, J., Roobol, M. J., et al. (2012). Pros-
with local/regional stage prostate carcinoma: findings from a tate-cancer mortality at 11 years of follow-up. N Engl J Med,
large community-based cohort. Cancer, 106(6), 1276e1285. 366(11), 981e990.

14. Behavioral Risk Factor Surveillance System Survey Data. Center 27. Wilt, T. J., Brawer, M. K., Barry, M. J., et al. (2009). The Prostate
for Disease Control and Prevention.(2009). http://www.cdc. cancer Intervention versus Observation Trial:VA/NCI/AHRQ
gov/brfss/. Accessed June 3, 2015. Cooperative Studies Program #407 (PIVOT): design and
baseline results of a randomized controlled trial comparing
15. Powell, I. J., Heilbrun, L., Littrup, P. L., et al. (1997). Outcome of radical prostatectomy to watchful waiting for men with clini-
african-american men screened for prostate cancer: the detroit cally localized prostate cancer. Contemp Clin Trials, 30(1),
education and early detection study. J Urol, 158(1), 146e149. 81e87.
16. Underwood, W., De Monner, S., Ubel, P., Fagerlin, A., Sanda, 28. Hicks, C., Koganti, T., Giri, S., et al. (2014). Integrative genomic
M. G., & Wei, J. T. (2004). Racial/ethnic disparities in in the analysis for the discovery of biomarkers in prostate cancer.
treatment of localized/regional prostate cancer. J Urol, 171(4), Biomark Insights, 29(9), 39e51.
1504e1507.
29. Helfand, B. T., Catalona, W. J., & Xu, J. (2015). A genetic-based
17. Ward, E., Jemal, A., Cokkinides, V., et al. (2004). Cancer dis- approach to personalized prostate cancer screening and
parities by race/ethnic and socioeconomic status. CA Cancer treatment. Curr Opin Urol, 25(1), 53e58.
J Clin, 54(2), 78e93.
30. Xu, J., Kibel, A. S., Hu, J. J., et al. (2009). Prostate cancer risk
18. Whittemore, A. S., Kolonel, L. N., Wu, A. H., et al. (1995). Prostate associated loci in African-Americans. Cancer Epidemiol Bio-
cancer in relation to diet, physical activity, and body size in mark Prev, 18(7), 2145e2149.
blacks, whites, and Asians in the United States and Canada.
31. Freedman, M. L., Haiman, C. A., Patterson, N., et al. (2006).
J Natl Cancer Inst, 87(9), 652e661.
Admixture mapping identified 8q24 as a prostate cancer risk
19. R. Jonathan Henderson, James A. Eastham, Culkin Daniel J., locus in African-American men. Proc Natl Acad Sci U S A,
Terence Whatley, John Mata, Dennis Venable, Michael W. Kat- 103(38), 14068e14073.
tan, and Oliver Sartor, Prostate-Specific Antigen (PSA) and PSA
32. David, S., & Chan, D. W. (2014). Biomarkers in prostate cancer:
Density: Racial Differences in Men without Prostate Cancer.
what’s new? Curr Opin Oncol, 26(3), 259e264.
20. Sutton, S. S., Crawford, E. D., Moul, J. W., Hardin, J. W., & Kruep, E.
33. Kader, K., Sun, J., Reck, B., et al. (2012). Potential impact of
(2016). Determining optimal prostate-specific antigen thresholds
adding genetic markers to clinical parameters in predicting
to identify an increased 4-year risk of prostate cancer devel-
prostate biopsy outcomes in men following an initial nega-
opment: an analysis within the Veterans Affairs Health Care
tive biopsy: findings from the REDUCE trial. Eur Urol, 62(6),
System. World J Urol. https://doi.org/10.1007/s00345-015-1754-6.
953e961.
21. Office of Research & Development. (n.d.). Retrieved October
34. Ansbaugh, N. (n.d.). ResultAgent Orange as a risk factor for
02, 2016, from http://www.research.va.gov/currents/0915-1.cfm.
high-grade prostate cancer Filters. Retrieved October 02, 2016;
22. Graham-Steed, Tisheeka, et al. (2013). ‘Race’ and Prostate https://www.ncbi.nlm.nih.gov/pubmed/23670242.
Cancer Mortality in Equal-access Healthcare Systems. Am J
35. Ansbaugh, N., Shannon, J., Mori, M., Farris, P. E., & Garzotto,
Med, 126(12), 1084e1088.
M. (2013). Agent orange as a risk factor for high-grade
23. Final recommendation statement: Prostate cancer: screening. prostate cancer. Cancer, 119(13), 2399e2404. https://doi.
U.S. Preventive services Task forcewebsite.(2014). Accessed org/10.1002/cncr.27941. http://link.springer.com/article/
June 4, 2015. 10.1007/s00345-015-1754-6.

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