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At the end of last year, the New York State Department of Health released its prostate cancer maps as part of Governor Pataki's Cancer Surveillance Improvement Initiative (CSII). The maps depict prostate cancer incidence across the state. One of the maps reveals that two Brooklyn neighborhoods, Bedford-Stuyvesant (Bed-Stuy) and Crown Heights, have "elevated incidence of late-stage prostate cancer." ("Late stage" means that the cancer has spread to other areas in the body.)
Crown Heights and Bed-Stuy are predominantly black, and black men in New York, as in the nation, have the highest rate of prostate cancer. Black men in New York State are one-and-a-half times more likely to get prostate cancer and twice as likely to die from it than white men. "It appears as though we are predisposed to prostate cancer," says Dr. Rupert Thompson, attending urologist at St. Mary's Brooklyn, a division of the Saint Vincent Catholic Medical Centers. The hospital treats prostate cancer patients from both neighborhoods. "The disease is a more aggressive disease in black men," says Dr. Errol Mallett, chief of urology at Interfaith Medical Center in Crown Heights. "We don't know why."
Although a gene that predisposes men to prostate cancer has been identified, only 8 percent of prostate cancer cases are inherited, according to Larry Thompson, director of communications at the National Human Genome Research Institute.
"I think it reflects cultural lifestyle or eating, like higher-fat diets," says Dr. Alfred I. Neugut, co-director of the Cancer Prevention Center at New York Presbyterian Hospital and professor of medicine and epidemiology at Columbia University College of Physicians and Surgeons. Black men in Africa have a lower incidence of prostate cancer, he says. If you take those African men and put them in the U.S., the next generation will have a prostate cancer incidence equal to that of African American men. "If it was genetic, this difference would not exist."
Diets high in fat are associated with cancer. "There is a higher correlation between fat and cancer than any other thing that is known," says Dr. Andre Balla, professor of pathology at the Medical College of Wisconsin. High-fat diets can lead to elevated levels of testosterone in men's blood, which can overstimulate the cells of the prostate, increasing cancer risk.
"It is more economics and living in a climate of stress," says Dr. Kamau B. Kokayi, medical director for the Kings County Acupuncture Clinic and head of a private primary-care holistic medical center in Park Slope, Brooklyn. Many men in the area, he says, who work two or three jobs, don't take care of themselves. "There is an aspect of being poor, an aspect of being black," he adds, "and an aspect of being in a material culture that causes stress."
Given that prostate cancer generally grows slowly, and doesn't have to spread, why aren't black men in Crown Heights and Bed-Stuy catching the disease before it spreads? Despite President Clinton's apology for the Tuskegee Syphilis Studyin which the U.S. Public Health Service conducted a 40-year experiment on the effects of untreated syphilis on 400 poor black menblacks often don't trust the medical system. There is a "great suspicion of the system" that goes back to Tuskegee, Thompson says. Kokayi agrees. "There is a general reluctance and hesitancy to deal with the system deliberately."
Dyer sees the vestiges of Tuskegee in resistance he finds when trying to recruit black men into clinical trials for CaP CURE. (CaP CURE was founded by former junk bond king Michael Milken after his prostate cancer diagnosis.) Says Dyer, "The clinical trials are full of white guys. . . . Tuskegee set a bad example." Delaying visits to doctors may then contribute to the high incidence of late-stage prostate cancer in Crown Heights and Bed-Stuy.
"What could be happening in that area is a lack of early diagnosis and treatment," says Kristine Smith, associate director of the health department's public affairs office. According to CSII, 14 percent of black men in New York State are diagnosed with the disease after it has spread, compared with 7.5 percent of white men. "We have been promoting screening vigorously," Mallett adds. However, "the turnout for the free screening is dismal."
Prostate cancer screening has two parts. The first is the prostate specific antigen (PSA) test. PSA is a protein produced by prostate cells, which is elevated in men with prostate cancer. The second is the digital rectal exam (DRE), which involves a physical examination for abnormalities of the prostate. The DRE is one reason for the poor turnout. Says Rupert Thompson, "The men might come by for the screening then disappear when they find out about the digital rectal exam."
Similarly, men's attitudes toward treatment may also aid the spread of the disease. Many of the men in the area who do get screened and are diagnosed with the cancer "don't want to get cut," says Thompson. "I don't think we've done a good job with men with allaying their fears," he says. Men fear the treatment's possible side effectsimpotence and incontinence. However, Thompson says, "Impotence can be spared and they can maintain their water." Dyer, who had a radical prostatectomy (removal of the entire prostate) says, "I'm next to perfect."
But treatment is dependent on access to doctors. Some of the men are not "plugged into the system," says an oncologist who treats late-stage cancer patients from the two neighborhoods and wants to remain anonymous. "What amount of this population is really going to the doctor?" And the quality of medical care may be an issue. Although there are a "handful of doctors with heart," Dyer says, there are those who, "because they are working in the bowels of Brooklyn, don't care." During a speech at a Brooklyn hospital Dyer mentioned PC-Spes, a dietary supplement used to extend the life expectancy of men with prostate cancer. Developed over four years ago, it is "widely used by every white man and intelligent black man," he says. After the talk, a doctor with 15 years of experience asked him, "What's PC-Spes?"
But these factors do not fully differentiate the black men in these neighborhoods from those in other black neighborhoods throughout the city. The answer may be in the Caribbean. A 1989 to 1994 study of 1121 cases of prostate cancer in men in Kingston, Jamaica, showed that they have a higher incidence of prostate cancer than black Americans. The study, which was conducted by Johns Hopkins University and Hopkins medical institutions, the James Buchanan Brady Urological Institute, and the University of the West Indies, is not the only one to support a Caribbean connection.
Dr. Rajiv Dhir, assistant professor and staff pathologist at the University of Pittsburgh Medical Center, is part of a group conducting a study of the incidence of prostate cancer in Trinidad and Tobago. The group, which is collaborating with local medical experts, has done DREs, PSA tests, and needle biopsies. So far, says Dhir, between 40 and 50 percent of the men have prostate cancer. Dhir says there is a "predilection for a higher grade" of prostate cancer. Why? "We don't really have a specific answer," says Dhir.
These studies are significant, Mallett says, because "there is a tremendous migration of Caribbean men to this area [Bed-Stuy and Crown Heights]." Thompson and Dyer also agree that there is a Caribbean connection. "It is the influx of Caribbean men," says Dyer, who is also from the Caribbean. "It has nothing to do with Brooklyn."