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When Black and white men in the United States are given the same treatment, the gap in dying of prostate cancer largely closes. The gap in dying of everything else does not. Cancer services measure the first and not the second, which means the surviving disparity is invisible to the people best placed to act on it.
Dess and colleagues pooled three cohorts with progressively tighter control of access: a registry, an equal-access surgical system and four randomised radiotherapy trials. After inverse probability weighting, the prostate cancer-specific hazard for Black men fell from 1.30 to 1.09 in the registry, was not significantly different in the equal-access cohort, and was significantly lower in the trial cohort. Other-cause mortality remained significantly higher in two of the three cohorts, at subdistribution hazard ratios of 1.30 and 1.17.
That pattern has a direct operational meaning. A prostate cancer service that achieves equal treatment has done most of what it can about prostate cancer death and none of what it could about the larger remaining gap. The men in question are on androgen deprivation, which causes weight gain, insulin resistance, dyslipidaemia, loss of bone and muscle and, in some analyses, cardiovascular events; they are seen regularly by the cancer service for years; and their cardiovascular and metabolic risk is managed, if at all, elsewhere. The proposal is narrow and measurable: report other-cause mortality alongside cancer-specific mortality in every prostate cancer service audit, split by deprivation quintile and ethnicity, and make it the outcome against which a hormone therapy cardiometabolic clinic is judged.
UK and NHS specifics (the National Screening Committee position, NICE technology appraisals and their recommendation numbers, Cancer Drugs Fund status, magnetic resonance imaging and radiotherapy capacity, National Prostate Cancer Audit indicators and trial access) belong on the UK and NHS page for prostate cancer and are not restated here.
One trial page on OnCo cites this paper by its DOI; this record gives the citation a page of its own so a reader can follow it without leaving OnCo. Read the abstract above alongside the citing page listed under Related; the record was created automatically from the Europe PMC entry and its figures have not been checked by hand.
The evidence base for setting the age at which screening starts by risk rather than by birthday. It is also a warning: the same score performs differently across ancestries, so a risk model built and validated in European cohorts will under-serve the men at highest risk.
The disparity in prostate cancer death among Black men in the United States is, stage for stage and treatment for treatment, largely a disparity in getting standard care rather than in tumour biology. The disparity that survives equal access is in dying of everything else, which is the part a cancer service is least organised to fix and most able to measure.
The current shape of the screening question in the United States, and the best short statement of the trade-off in numbers a man can weigh. The three-to-one ratio between metastatic cases prevented and deaths prevented is also the argument for using metastatic presentation, not mortality, to judge a screening programme sooner.
The reason intermittent androgen deprivation is offered as a choice in metastatic disease rather than recommended, and a case study in what an inconclusive non-inferiority trial should say. For a man weighing the side effects, the honest statement is that the quality-of-life gain is real but brief and the survival question is open.
Shares Transdermal oestradiol for androgen suppression in prostate cancer: long-term cardiovascular outcomes from the randomised Prostate Adenocarcinoma Transcutaneous Hormone (PATCH) trial programme, Androgen deprivation therapy (ADT), Metastatic hormone-sensitive prostate cancer, Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch and the tag prostate-evidence.
Shares Other-cause mortality, Quality of life, Localised prostate cancer, intermediate risk, Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch and the tag prostate-evidence.
Shares Other-cause mortality, Localised prostate cancer, intermediate risk, Localised prostate cancer, high and very high risk, Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch and the tag prostate-evidence.
Shares Trans-ancestry genome-wide association meta-analysis of prostate cancer identifies new susceptibility loci and informs genetic risk prediction, Metastatic hormone-sensitive prostate cancer, Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch, Fragmented care and guideline gaps and the tag prostate-evidence.
Shares Androgen deprivation therapy (ADT), Metastatic hormone-sensitive prostate cancer, Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch, Prostate cancer and the tag prostate-evidence.
Shares Localised prostate cancer, intermediate risk, Localised prostate cancer, high and very high risk, Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch, Prostate cancer and the tag prostate-evidence.
Shares SWOG 9346: intermittent versus continuous androgen deprivation in metastatic prostate cancer, Quality of life, Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch, Prostate cancer and the tag prostate-evidence.
Shares USPSTF 2018: screening for prostate cancer, recommendation statement (grade C at 55 to 69, grade D at 70 and over), Localised prostate cancer, intermediate risk, Localised prostate cancer, high and very high risk, Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch and the tag prostate-evidence.