Access and Representation: A Narrative Review of the Disparities in Access to Clinical Trials and Precision Oncology in Black men with Prostate Cancer

Published:September 25, 2021DOI:



      To provide commentary on the disparities in access to clinical trials and precision oncology specific to Black men with Prostate Cancer (PCa) in the United States and lend a general framework to aid in closing these gaps.

      Materials and Methods

      The ideas, commentaries and data presented in this narrative review were synthesized by utilizing qualitative and quantitative studies, reviews, and randomized control trials performed between 2010 and 2021. We searched PubMed using the key words “Medicaid”, “Medicare”, “clinical trials”, “African Americans”, “Black”, “underrepresentation”, “access”, “Prostate Cancer”, “minority recruitment”, “racial disparities”, “disparity”, “genomics”, “biomarkers”, “diagnostic” “prognostic”, “validation”, “precision medicine”, and “precision oncology” to identify important themes, trends and data described in the current review. Keywords were used alone and combination with both “AND” and “OR” terms.


      Black men with prostate cancer (PCa) in the United States have earlier onset of disease, present with more advanced stages, and worse prostate cancer-specific survival than their White counterparts. Potential causative factors vary from disparities in health care access to differences in tumor immunobiology and genomics along with disparate screening rates, management patterns and underrepresentation in clinical and translational research such as clinical trials and precision oncology.


      To avoid increasing the racial disparity in PCa outcomes for Black men, we must increase inclusion of Black men into precision oncology and clinical trials, using multilevel change. Underrepresentation in clinical and translational research may potentiate poorly validated risk calculators and biomarkers, leading to poor treatment decisions in high-risk populations. Relevant actions include funding to include minority-serving institutions as recruitment sites, and inclusion of evidence based recruitment methods in funded research to increase Black representation in clinical trials and translational research.
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        • Siegel RL
        • Miller KD
        • Jemal A
        Cancer statistics, 2020.
        CA: Cancer J Clins. 2020; 70: 7-30
        • DeSantis CE
        • Siegel RL
        • Sauer AG
        • et al.
        Cancer statistics for African Americans, 2016: progress and opportunities in reducing racial disparities.
        CA: Cancer J Clin. 2016; 66: 290-308
        • Ravery V
        • Dominique S
        • Hupertan V
        • et al.
        Prostate cancer characteristics in a multiracial community.
        Eur Urol. 2008; 53: 533-539
        • Evans S
        • Metcalfe C
        • Patel B
        • et al.
        Clinical presentation and initial management of Black men and white men with prostate cancer in the United Kingdom: The process cohort study.
        British Journal of Cancer. 2009; 102: 249-254
        • Dess RT
        • Hartman HE
        • Mahal BA
        • et al.
        Association of Black race with prostate cancer–specific and other-cause mortality.
        JAMA Oncol. 2019; 5: 975
        • Smith ZL
        • Eggener SE
        • Murphy AB
        African-American prostate cancer disparities.
        Curr Urol Rep. 2017; 18: 1-10
        • Barocas DA
        • Grubb R
        • Black A
        • et al.
        Association between race and follow-up diagnostic care after a positive prostate cancer screening test in the prostate, lung, colorectal, and ovarian cancer screening trial.
        Cancer. 2013; 119: 2223-2229
        • Mahal BA
        • Ziehr DR
        • Aizer AA
        • et al.
        Getting back to equal: The influence of insurance status on racial disparities in the treatment of African American men with high-risk prostate cancer.
        Urol Oncol: Semin Orig Inve. 2014; 32: 1285-1291
        • Powell IJ
        • Chinni SR
        • Reddy SS
        • Zaslavsky A
        • Gavande N
        Pro-inflammatory cytokines and chemokines initiate multiple prostate cancer biologic pathways of cellular proliferation, heterogeneity and metastasis in a racially diverse population and underlie the genetic/biologic mechanism of racial disparity: Update.
        Urol Oncol: Semin Orig Inve. 2021; 39: 34-40
        • Koga Y
        • Song H
        • Chalmers ZR
        • et al.
        Genomic profiling of prostate cancers from men with african and european ancestry.
        Clin Cancer Res. 2020; 26: 4651-4660
        • Ahaghotu C
        • Tyler R
        • Sartor O
        African American participation in oncology clinical trials—Focus on prostate cancer: implications, barriers, and potential solutions.
        Clin Genitourin Cancer. 2016; 14: 105-116
        • Balakrishnan AS
        • Palmer NR
        • Fergus KB
        • et al.
        Minority recruitment trends in phase III prostate cancer clinical trials (2003 to 2014): progress and critical areas for improvement.
        J Urol. 2019; 201: 259-267
        • Chornokur G
        • Dalton K
        • Borysova ME
        • Kumar NB
        Disparities at presentation, diagnosis, treatment, and survival in African American men, affected by prostate cancer.
        Prostate. 2010; 71: 985-997
        • Sweeney CJ
        • Chen Y
        • Carducci M
        • et al.
        Chemohormonal therapy in metastatic hormone-sensitive prostate cancer.
        N Engl J Med. 2015; 373: 737-746
        • Halabi S
        • Dutta S
        • Tangen CM
        • et al.
        Overall survival of black and white men with metastatic castration-resistant prostate cancer treated with docetaxel.
        J Clin Oncol. 2019; 37: 403-410
        • Spratt DE
        • Osborne JR
        Disparities in castration-resistant prostate cancer trials.
        J Clin Oncol. 2015; 33: 1101-1103
        • Oren O
        • Oren M
        • Beach D
        On the generalizability of prostate cancer studies: why race matters.
        Ann Oncol. 2016; 27: 2146-2148
        • Hamel LM
        • Penner LA
        • Albrecht TL
        • Heath E
        • Gwede CK
        • Eggly S
        Barriers to clinical trial enrollment in racial and ethnic minority patients with cancer.
        Cancer Control. 2016; 23: 327-337
        • Vaishampayan UN
        • Heilbrun LK
        • Monk 3rd, P
        • et al.
        Clinical efficacy of enzalutamide vs bicalutamide combined with androgen deprivation therapy in men with metastatic hormone-sensitive prostate cancer: a randomized clinical trial.
        JAMA Netw Open. 2021; 4e2034633
        • Langford AT
        • Resnicow K
        • Dimond EP
        • et al.
        Racial/ethnic differences in clinical trial enrollment, refusal rates, ineligibility, and reasons for decline among patients at sites in the national cancer institute's community cancer centers program.
        Cancer. 2013; 120: 877-884
        • Strekalova YA
        When trust is not enough: a serial mediation model explaining the effect of race identity, eHealth information efficacy, and information behavior on intention to participate in clinical research.
        Health Educ Behav. 2018; 45: 1036-1042
        • Brooks SE
        • Muller CY
        • Robinson W
        • et al.
        Increasing minority enrollment onto clinical trials: practical strategies and challenges emerge from the NRG oncology accrual workshop.
        J Oncol Pract. 2015; 11: 486-490
        • Eggly S
        • Barton E
        • Winckles A
        • Penner LA
        • Albrecht TL
        A disparity of words: racial differences in oncologist-patient communication about clinical trials.
        Health Expect. 2013; 18: 1316-1326
        • Ku S
        • Gleave ME
        • Beltran H
        Towards precision oncology in advanced prostate cancer.
        Nature Reviews Urol. 2019; 16: 645-654
        • Kretschmer A
        • Tilki D
        Biomarkers in prostate cancer – current clinical utility and future perspectives.
        Crit Rev Oncol/Hematol. 2017; 120: 180-193
        • Yamoah K
        • Deville C
        • Vapiwala N
        • et al.
        African American men with low-grade prostate cancer have increased disease recurrence after prostatectomy compared with Caucasian men.
        Urol Oncol: Semin Orig Inv. 2015; 33: 70.e15-70.e22
        • Khani F
        • Mosquera JM
        • Park K
        • et al.
        Evidence for molecular differences in prostate cancer between African American and Caucasian men.
        Clinl Cancer Res. 2014; 20: 4925-4934
        • Murphy AB
        • Carbunaru S
        • Nettey OS
        • et al.
        A 17-Gene panel Genomic prostate score has similar predictive accuracy for adverse pathology at radical prostatectomy in African American and European American men.
        Urology. 2020; 142: 166-173
        • Babajide R
        • Carbunaru S
        • Nettey OS
        • et al.
        Performance of prostate health index in biopsy naive black men.
        J Urol. 2021; 205: 718-724
        • Ankerst DP
        • Straubinger J
        • Selig K
        • et al.
        A contemporary prostate biopsy risk calculator based on multiple heterogeneous cohorts.
        Eur Urol. 2018; 74: 197-203
        • Carbunaru S
        • Nettey OS
        • Gogana P
        • et al.
        A comparative effectiveness analysis of the PBCG vs PCPT risks calculators in a multi-ethnic cohort.
        BMC Urol. 2019; 19: 1-9
        • O'Malley PG
        • Nguyen DP
        • Al Hussein Al Awamlh B
        • et al.
        Racial variation in the utility of urinary biomarkers PCA3 and T2ERG in a large multicenter study.
        J Urol. 2017; 198: 42-49
        • Parekh DJ
        • Punnen S
        • Sjoberg DD
        • et al.
        A multi-institutional prospective trial in the USA confirms that the 4Kscore accurately identifies men with high-grade prostate cancer.
        Eur Urol. 2015; 68: 464-470
        • Schwen ZR
        • Tosoian JJ
        • Sokoll LJ
        • et al.
        Prostate health index (PHI) predicts high-stage pathology in African American men.
        Urology. 2016; 90: 136-140
        • Klein EA
        • Cooperberg MR
        • Magi-Galluzzi C
        • et al.
        A 17-gene assay to predict prostate cancer aggressiveness in the context of gleason grade heterogeneity, tumor multifocality, and biopsy undersampling.
        Eur Urol. 2014; 66: 550-560
        • Sanda MG
        • Cadeddu JA
        • Kirkby E
        • et al.
        Clinically localized prostate cancer: Aua/Astro/Suo guideline. Part I: risk stratification, shared decision making, and care options.
        J Uroly. 2018; 199: 683-690
        • Schaeffer E
        • Srinivas S
        • Antonarakis ES
        • et al.
        NCCN guidelines insights: prostate cancer, version 1.2021.
        J Natl Compr Canc Netwr. 2021; 19: 134-143
        • Leapman MS
        • Wang R
        • Ma S
        • et al.
        Regional adoption of commercial gene expression testing for prostate cancer.
        JAMA Oncol. 2021; 7: 52
        • Sundi D
        • Kryvenko ON
        • Carter HB
        • Ross AE
        • Epstein JI
        • Schaeffer EM
        Pathological examination of radical prostatectomy specimens in men with very low risk disease at biopsy reveals distinct zonal distribution of cancer in Black American men.
        J Urol. 2014; 191: 60-67
        • Sanchez-Ortiz RF
        • Troncoso P
        • Babaian RJ
        • Lloreta J
        • Johnston DA
        • Pettaway CA
        African-American men with nonpalpable prostate cancer exhibit greater tumor volume than matched white men.
        Cancer. 2006; 107: 75-82
        • Vora A
        • Large T
        • Aronica J
        • et al.
        Predictors of Gleason score upgrading in a large African-American population.
        Int Urol Nephrol. 2013; 45: 1257-1262
        • Abern MR
        • Bassett MR
        • Tsivian M
        • et al.
        Race is associated with discontinuation of active surveillance of low-risk prostate cancer: Results from the Duke prostate center.
        Prostate Cancer Prostatic Dis. 2012; 16: 85-90
        • Deka R
        • Courtney PT
        • Parsons JK
        • et al.
        Association between African American race and clinical outcomes in men treated for low-risk prostate cancer with active surveillance.
        JAMA. 2020; 324: 1747
        • Krishna S
        • Fan Y
        • Jarosek S
        • Adejoro O
        • Chamie K
        • Konety B
        Racial disparities in active surveillance for prostate cancer.
        J Urol. 2017; 197: 342-349
        • Miyahira AK
        • Sharp A
        • Ellis L
        • et al.
        Prostate cancer research: the next generation; report from the 2019 coffey-holden prostate cancer academy meeting.
        Prostate. 2019; 80: 113-132
        • Cheng HH
        The resounding effect of DNA repair deficiency in prostate cancer.
        Urol Oncol: Semin Orig Inves. 2018; 36: 385-388
        • Khemlina G
        • Ikeda S
        • Kurzrock R
        Molecular landscape of prostate cancer: implications for current clinical trials.
        Cancer Treat Rev. 2015; 41: 761-766
        • Warner EW
        • Yip SM
        • Chi KN
        • et al.
        DNA repair defects in prostate cancer: impact for screening, prognostication and treatment.
        BJU Int. 2018; 123: 769-776
        • Chang B
        • Spangler E
        • Gallagher S
        • et al.
        Validation of genome-wide prostate cancer associations in men of African descent.
        Cancer Epidemiol Biomarkers Prev. 2010; 20: 23-32
        • Castro E
        • Goh C
        • Olmos D
        • et al.
        Germline BRCA mutations are associated with higher risk of nodal involvement, distant metastasis, and poor survival outcomes in prostate cancer.
        J Clin Oncol. 2013; 31: 1748-1757
        • Mateo J
        • Carreira S
        • Sandhu S
        • et al.
        DNA-repair defects and olaparib in metastatic prostate cancer.
        N Engl J Med. 2015; 373: 1697-1708
        • Hong MK
        • Macintyre G
        • Wedge DC
        • et al.
        Tracking the origins and drivers of subclonal metastatic expansion in prostate cancer.
        Nat Commun. 2015; 6
        • Grasso CS
        • Wu Y
        • Robinson DR
        • et al.
        The mutational landscape of lethal castration-resistant prostate cancer.
        Nature. 2012; 487: 239-243
        • Gundem G
        • Van Loo P
        • Kremeyer B
        • et al.
        The evolutionary history of lethal metastatic prostate cancer.
        Nature. 2015; 520: 353-357
        • Mullane SA
        • Van Allen EM
        Precision medicine for advanced prostate cancer.
        Curr Opin Urol. 2016; 26: 231-239
        • Joshi A
        • Roberts MJ
        • Alinezhad S
        • et al.
        Challenges, applications and future directions of precision medicine in prostate cancer – the role of organoids and patient-derived xenografts.
        BJU Int. 2020; 126: 65-72
        • Morales J
        • Welter D
        • Bowler EH
        • et al.
        A standardized framework for representation of ancestry data in genomics studies, with application to the NHGRI-EBI GWAS catalog.
        Genome Biol. 2018; 19: 1-10
        • Lewis DD
        • Cropp CD
        The impact of African ancestry on prostate cancer disparities in the era of precision medicine.
        Genes. 2020; 11: 1471
        • Berndt SI
        • Wang Z
        • Yeager M
        • et al.
        Two susceptibility loci identified for prostate cancer aggressiveness.
        Nat Commun. 2015; 6: 1-7
        • Eeles RA
        • Olama AA
        • Benlloch S
        • et al.
        Identification of 23 new prostate cancer susceptibility loci using the iCOGS custom genotyping array.
        Nat Genet. 2013; 45: 385-391
        • Knipe DW
        • Evans DM
        • Kemp JP
        • et al.
        Genetic variation in prostate-specific antigen–detected prostate cancer and the effect of control selection on genetic association studies.
        Cancer Epidemiol Biomarkers Prev. 2014; 23: 1356-1365
        • Kote-Jarai Z
        • Olama AA
        • Giles GG
        • et al.
        7prostate cancer susceptibility loci identified by a multi-stage genome-wide association study.
        NatGenet. 2011; 43: 785-791
        • Lange EM
        • Johnson AM
        • Wang Y
        • et al.
        Genome-wide association scan for variants associated with early-onset prostate cancer.
        PLoS ONE. 2014; 9: e93436
        • Lose F
        • Batra J
        • O'Mara T
        • et al.
        Common variation in Kallikrein genes klk5, klk6, klk12, and KLK13 and risk of prostate cancer and tumor aggressiveness.
        Urol Oncol: Semin Orig Inve. 2013; 31: 635-643
        • Waters KM
        • Le Marchand L
        • Kolonel LN
        • et al.
        Generalizability of associations from prostate cancer genome-wide association studies in multiple populations.
        Cancer Epidemiol Biomarkers Prev. 2009; 18: 1285-1289
        • Xu J
        • Lange EM
        • Lu L
        • et al.
        HOXB13 is a susceptibility gene for prostate cancer: results from the international consortium for prostate cancer genetics (ICPCG).
        Hum Genet. 2012; 132: 5-14
        • Hooker S
        • Hernandez W
        • Chen H
        • et al.
        Replication of prostate cancer risk loci on 8q24, 11q13, 17q12, 19q33, and Xp11 in African Americans.
        Prostate. 2009; 70: 270-275
        • Dubrovska A
        • Elliott J
        • Salamone RJ
        • et al.
        CXCR4 expression in prostate cancer progenitor cells.
        PLoS ONE. 2012; 7: e31226
        • Dubrovska A
        • Elliott J
        • Salamone RJ
        • et al.
        CXCR4 expression in prostate cancer progenitor cells.
        PLoS ONE. 2012; 7: e31226
      1. U.S. Department of Health and Human Services. (n.d.).
        NIH policy and guidelines on the inclusion of women and minorities as subjects in clinical research. National Institutes of Health, Retrieved May 4, 2021
        • National Cancer Institute Community Oncology Research Program
        The NCI community oncology research program (NCORP).
        The National Cancer Institute Community Oncology Research Program (NCORP), 2021 (Available at:)
        • Popejoy AB
        • Fullerton SM
        Genomics is failing on diversity.
        Nature. 2016; 538: 161-164
        • Rogers CR
        • Rovito MJ
        • Hussein
        • et al.
        Attitudes toward Genomic testing and prostate cancer research among Black men.
        Am J Prevent Med. 2018; 55: S103-S111
        • Ojukwu E
        • Powell LR
        • Person SD
        • Rosal MC
        • Lemon SC
        • Allison J
        Spirituality and willingness to participate in health-related research among African Americans.
        J Health Care for the Poor Underserved. 2018; 29: 400-414
        • Niu X
        • Roche LM
        • Pawlish KS
        • Henry KA
        Cancer survival disparities by health insurance status.
        Cancer Med. 2013; 2: 403-411
        • Lewis DD
        • Cropp CD
        The impact of African ancestry on prostate cancer disparities in the era of precision medicine.
        Genes. 2020; 11: 1471