At the 2024 ASTRO Annual Meeting, Kosj Yamoah, MD, PhD, presented the final results from the VANDAAM study, which validated the Decipher Prostate Genomic Classifier (Veracyte, Inc) in the African American population.

Following these proceedings, featured expert William K. Oh, MD, was interviewed by Conference Reporter Editor-in-Chief Tom Iarocci, MD. Dr Oh’s clinical perspectives on this topic are presented here.

Health disparities among African Americans is a historic and long-standing concern. It is clear that African American men do worse with prostate cancer than other groups. For example, these individuals are diagnosed at earlier ages, have a higher incidence and rate of advanced disease, and have a mortality rate that is approximately is 2 to 3 times higher than that of White patients.

Even those who are diagnosed with low-risk prostate cancer (ie, grade group 1) have a higher mortality rate. This may be explained by a higher likelihood of pathologic upgrading among African Americans, which fits with the idea that higher-grade lesions (grade group ≥2) within the pretreatment biopsies are less likely to be detected in this group. This is seen in studies such as the one by Sundi et al, which adjusted for many potential confounders (eg, prostate-specific antigen, prostate size, volume of cancer on biopsy, treatment year, and body mass index) and found that African American race was a predictor of biopsy reclassification by grade. By extension, one could suggest that active surveillance may be a less effective strategy in African American men; however, in my view, the most important conclusion is that screening may have different benefits for different populations.

The underlying reasons for disparities (eg, biology vs socioeconomic factors vs cultural influences) are frequently discussed. However, if you put the reasons aside and take as your starting point that somebody who identifies as African American is more likely to be diagnosed earlier in life and to die of prostate cancer, then you can develop specifically tailored strategies for screening and testing.

That is what we did in our recent paper published in NEJM Evidence, which addressed prostate cancer screening specifically in African American population. In this publication, we wanted to clearly and unequivocally state the evidence behind earlier screening. Essentially, we concluded that, among men who elect screening, their first prostate-specific antigen testing should be between the ages of 40 and 45 years, and screening should be annual thereafter, with the consideration of stopping at age 70 years. In my view, earlier screening and detection probably makes a bigger difference in African American men and in men with the genetic or family risk history than it does in the general population.

At ASTRO 2024, Dr Yamoah, from the H. Lee Moffitt Cancer Center & Research Institute, presented the final results of the VANDAAM study, showing the utility of the Decipher Prostate Genomic Classifier, which has become an important option for molecular testing (abstract 335). I am using Decipher quite a bit to help stratify patients with localized disease, and I think this classifier can be helpful in informing treatment decision making. The VANDAAM study results showed that there was no difference between African American men and White men in terms of the ability of Decipher to predict outcomes. I think that studies like this are valuable because, while we need to see when there are differences by race, we also need to see when there are no differences. A genomic classifier such as Decipher can be valuable in helping to make clinical decisions regardless of race. I think that VANDAAM was an important study in this regard.

We do need more options for genetic and germline testing, and we do need to understand the biology and whether there are differences in hormonal activation in this population. Unfortunately, there has been an underengagement of African American men in germline testing and in clinical trials, which can limit the benefits of precision therapy and tailored screening. To address these disparities, an “all-of-the-above” strategy has been proposed in terms of interpersonal-, institutional-, community-, and policy-/advocacy-based outreach.

We know that cultural factors matter. Another abstract at ASTRO 2024, the “Centering Black Voices” abstract, presented by Charlyn Gomez, BS, from the University of Maryland School of Medicine, highlighted this point (abstract 215). The authors examined the beliefs of African Americans regarding clinical trials. Anecdotally, I have had difficulty convincing some of my African American patients to consider clinical trials, even when they like and trust me. What this abstract highlighted was quite fascinating in that the survey respondents liked and trusted their doctors, but they still did not trust the idea of a clinical trial, for reasons that included cultural and spiritual factors.