LAUSR

One of the most enthralling of the disparities in health is that seen in prostate cancer. Prostate cancer incidence and mortality have consistently been higher in Black men than White men. In 2018, according to US Surveillance, Epidemiology, and End Results registry data, Black men had a 66% higher incidence and twice the death rate. This pattern was observed well before 1990 when the era of aggressive screening and treatment of localized disease began. Why do Black men have a higher risk of prostate cancer diagnosis (incidence) and a higher risk of prostate cancer death (mortality)? Is this due to inherent genetics? Is the reason environmental? Is treatment less effective in Black men? What is the role of race in prostate cancer risk? In this issue of Cancer, 2 studies provide some clarity and understanding concerning some longstanding questions, especially those regarding race and outcomes. Wilkins et al assessed the efficacy of radical prostatectomy for highgrade, localized prostate cancer by race. They found that equalquality treatment was equally efficacious in Black and White men with localized grade group 4 or 5 disease who could obtain treatment at 3 highvolume referral centers. Studying men presenting at a large number of US hospitals in the US National Cancer Database, Wen et al assessed the effectiveness of prostate cancer treatment, primarily radical prostatectomy, in the United States. They found that Black men with highgrade, localized disease treated with radical prostatectomy had a 51% higher mortality rate (hazard ratio [HR], 1.51; 95% confidence interval, 1.471.56). After adjustments for education, median household income, and insurance status, the survival disparity decreased to 30% (HR, 1.30; P < 1.00E– 12). With adjustments for nonclinical factors, serum prostatespecific antigen levels, and comorbidities, the disparity was further reduced to 19% (HR, 1.19; P < 1.00E– 12). Wen et al’s study is one of the few that have assessed outcomes among Asian American/Pacific Islander (AAPI) and Hispanic patients. It leaves us asking why AAPI and Hispanic patients as a group have better outcomes than Whites. The discussion focuses always on the BlackWhite disparity and not on the fact that there are WhiteAAPI and WhiteHispanic disparities. The answer to the question “Why the differences?” could have a substantial benefit for Blacks and Whites. A most important finding is that the treatment can work equally well in Blacks and Whites. The efficacy study shows that there is no disparity in the death rate when all factors are optimized. This finding is consistent with previous observations suggesting that equal treatment yields equal outcomes among equal patients for localized and higher stage prostate cancer. The effectiveness study assesses realworld outcomes. It shows the influence of social issues in medicine and health. There is a substantial literature showing that Blacks are less likely to receive appropriate, highquality treatment for prostate and other cancers in comparison with Whites. These 2 articles along with a still developing literature suggest that overcoming negative social/logistical factors can prevent or significantly reduce disparities in outcomes. Corrections for education, median household income, and insurance were the most potent of the modifiable factors, with correction for the disparity in comorbid diseases being next. The correction for comorbid disease requires real social change. The common clinical application of race as a biological risk factor is under significant challenge. These articles are timely because of the recent statement by the American Medical Association recognizing race as a social construct rather than a biological risk factor. This is progress because it will lead to a deeper understanding of socioeconomic status (SES) and racism as determinants of health and help us to address these issues.