Recurrence after Radical Prostatectomy: Is It Different in Black Men

PUBLIC ABSTRACT

Training in a socialized medicine system (in Brazil) provided me with a unique insight into how, although the system is designed to deliver care to all, it underserves minorities and the economically disadvantaged. On completing my training in Urology in Brazil, I sought to obtain research skills that would give me a global perspective on the excess disease burden among minorities. I was fortunate to join a group that offered me an all inclusive outlook on how clinical research is done. I was immediately attracted to prostate cancer (PCa) because of its prevalence and the clinical challenges it represents. Also, I realized even in the United States where technical expertise in medicine is among the best, disease prevalence and health care delivery are inequitably distributed among minorities. Under the guidance of Dr. Stephen J. Freedland, I was actively involved in outcomes research using data from men within the Shared Equal Access Regional Cancer Hospital (SEARCH) Database. Even in an equal access setting, such as the Veterans Affairs hospitals, I saw African American men (AAM) had more aggressive disease and were more likely to develop disease recurrence after radical prostatectomy. This prompted me to study the use of secondary treatments after recurrence and how patients' characteristics such as age and race influence the use of such treatments. Also, I partook in all the academic programs of the Division of Urology in Duke University. In short, working with this group has provided me with the initial impetus and broad base which will help my transition into a health disparities researcher.

Many milestones in modern medicine were achieved by answering research questions that initially arose from the bedside. Thus, after completing this research fellowship, I will finish my training in urology followed by a clinical fellowship in urologic oncology. The training I receive in the course of these two years of research will provide me the requisite tools to optimize my time for focused research on health disparities during the residency and clinical fellowship period. Ultimately, I aim to practice medicine as an academic urologist with a particular focus on PCa research and health disparities. This will allow me the opportunity to impart the knowledge I gain to future generations of physicians and researchers and help shape their minds to the cause of minimizing the excess burden of disease among minorities.

My two-year training program includes research and interactive learning components involving coursework, seminars, journal clubs, and conferences under the supervision of Dr. Freedland, a well-known authority in the field of PCa racial disparity. Given his successes, he is an outstanding role model and someone I would like to emulate. The didactic portion will involve formal training through completion of a Masters of Public Health (MPH) in Epidemiology at the University of North Carolina at Chapel Hill -- one of the top public health programs in the United States. This program will provide a solid foundation of population health knowledge and research skills on which to build. The coursework will emphasize racial inequalities in the US.

In this project, I will study the natural history of patients with recurrent PCa initially treated with surgery, and the impact of additional treatments on the risk of developing metastasis and dying of the cancer. In addition, I will examine whether racial disparities exist in the response to these additional treatments. Based on previous studies, AAM have worse disease, present with more advanced stages, receive less aggressive treatment, and have a higher mortality. AAM also develop disease recurrence after surgery more frequently than CM. Thus, it is essential to understand the effect of race on subsequent treatments after surgery. Furthermore, given these treatments are not free of side-effects, I will also study the incidence of the most worrisome adverse effects of hormonal treatment (a frequently used treatment for recurrent disease). It is well known that AAM have a higher incidence of diabetes, cardiovascular disease, and lipid abnormalities. We also know that hormonal treatment increases cholesterol, glucose levels, and atherosclerosis leading to diabetes and cardiovascular events. Thus, it is vital to know whether AAM bear a disparate burden of side-effects from additional treatments.

We expect treatments after surgery will decrease the risk of metastasis and prolong life. As such, those with the worst disease (i.e. those at the highest risk for metastasis and death) stand the most to benefit from these treatments. Unfortunately, although AAM have an increased risk for metastasis and death and thus stand the most to benefit, we expect that these treatments will actually be less effective among AAM as we hypothesize their disease is inherently more resistant to treatment. In addition, we anticipate hormonal therapy will be associated with increased cardiovascular disease and diabetes, and these risks will be higher among AAM as they have greater co-morbidities and are theoretically more susceptible to hormones side-effects. If confirmed, our results will assist physicians and patients in deciding upon the best treatment strategy for recurrent PCa after surgery and in turn help minimize racial disparities in PCa.