Christine Gardella, PA-S2St. Franscis University

AA =African American CaP = Cancer of the ProstateBrCa = Breast Cancer

African Americans have the highest death rate & shortest survival of any racial or ethnic group in US for most cancers.1

The death rate is 32% higher in African American men and 16 % higher in African American women as compared to white men and women.1

168,900 New Cancer Cases

Most commonly diagnosed cancers:◦Prostate 40% ◦Breast 34%◦Lung 15% 13% ◦Colon or rectum 9% 11%

65,540 Deaths from Cancer in 2011 Higher in AAs than Whites since 1975

AA Women liklier to die from cancer of the◦ Breast ◦ Colorectum

AA Men liklier to die from cancer of the◦ Prostate◦ Lung & Bronchus ◦ Colorectum

5 year survival rates indicate whether early detection may have occurred

Overall 5-year survival rates have improved from 25% (1963) to 59% (2006)

However, AAs are less likely to survive 5 years at each stage of diagnosis for most cancer sites as compared to Whites

CaP the leading cause of cancer among AA ’s

1 in 5 AAs diagnosed in their lifetime

For reasons that are unclear, incidence rates are 60% higher in African American men than in white men

2.4 times the death rate than in white men

2nd leading cause of cancer death in AAs

Death increases inversely to years of education

5-year survival rate is 96% as compared to 100% in whites

29% survival rate when spread to distant sites

F amily history A ge of the African American C aribbean descent increases risk even more T ests annually for PSA and DRE are needed

at age 40

Risk factors increase when 1st degree relative recieves diagnosis before age 65 by 4 times.

Changes in caliber during urination Dysuria Hematuria Pelvic pain Bladder fullness Fatigue Malaise Weight loss Back pain, hip pain Hemoptysis, cough, chest pain Abdominal pain, jaundice

African American without increased risk factors should begin screening at age 45

Increased risk factors, such as significant family history, should begin at age 40

Digital rectal exam (DRE)

Prostate antigen test (PSA)

Need both screens annuallyo 10% cancers are NOT detected through PSA alone

Understand there may be fear, misperceptions & mistrust held by your patient

Be clear with the risks and benefits in allowing or foregoing the DRE and the PSA

If your patient is religiously involved, he may respond positively to the message that his faith wishes him to take care of “God’s temple” or to “take care of his body and soul” through exams and testing3

Protein specific antigen produced by the prostate

Measured by simple blood test

Elevated levels can indicate cancer

False positives (no cancer)

False negatives (missed cancers)

 A sensitivity of 86%, specificity of 33%, and positive predictive value of 41% have been identified for PSA levels higher than 4.0 ng/mL1

Traditional method:

Absolute PSA levels NMT >4.0 ng/mL

◦ Elevated levels should be followed by a serum acid phosphatase test (AcPase)

Age related levels now used◦ ie PSA NMT >2.5 ng/mL in younger men

PSA velocity/rate of rise

PSA density vs. prostate size

PSA Free to total ratio

PSA F/T Ratio is an inverse relationship to probable cancer diagnosis on 12-core biopsy.

Low Ratio (< 0.11) = High Gleason score (7-10)

there is cancer

High Ratio (> 0.11) = Low Gleason score (<7) there is no cancer

A strategy of CaP staging which predicts prognosis and helps guide therapy. A Gleasonscore is given to CaP based upon itsmicroscopic appearancefrom biopsy. Cancers

with a higher Gleason score are more aggressive and have a worse prognosis.

If 1 of the following: PSA level has doubled in fewer than 3

years PSA velocity of greater than 0.75 ng/mL

per year Prostate biopsy showing evidence of

worsening cancer1

With an abnormal DRE

10-25 second exam

Patient in lithotomy position. Gloved and lubricated index finger carefully insert into rectum. Palpate the prostate through the rectal wall for the sulcus, medial & lateral lobes from left to right; note any changes in size, texture, firmness, symmetry.

Of note: adenocarcinoma usually begins in the non-palpable posterior lobe.2

Document normal exam findings: “Smooth, firm, walnut sized gland without palpable mass/nodules, indurations, softness or tenderness. Seminal vesicles are non-palpable.”

http://www.youtube.com/watch?v=ggIdvLLAgvQ

Create Community Involvement: Identify local barbers and hair salons considered leaders in the AA community

Share this connection:The Prostate Net®

P. O. Box 2192Secaucus, NJ 07096Tel: 888.477.6763Fax: 270.294.1565

Partnership between practice and community saves lives

http://www.prostate-online.org/barber.html

Let’s Talk About It: A free community-based program developed by the American Cancer Society and 100 Black Men of America, Inc. to increase awareness and knowledge about prostate cancer.

For more information about prostate cancer, or to find out how to hold a Let's Talk About It event in your community, contact your local American Cancer Society or toll-free at 1-800-227-2345

Most commonly diagnosed cancer among African American women

Among AA women under age of 45 incidence rates are higher than whites.

More likely to have poorer prognosis: higher grade, distal stage, negative hormone receptor status.

Premenopausal women higher risk for the more aggressive subtype basal-like BrCa

2nd most common cause of death due to cancer among AA women

Decline in death rates over the past decade at slower rate as compared to whites by 39%.

5-year survival rate is 78% as compared to 90% in whites

At diagnosis – 51% local stage cancer as compared to 61% whites

Age: risk increases with age Personal or family history Race: diagnosed more in whites but more

aggressive in AA women Hx of chest radiation treatment Density of breast tissue Breast changes with DCIS, LCIS, or precancer

biopsies Age of menarche or unopposed estrogen and

progesterone exposure throughout lifespan DES exposure

Having BRCA 1 & 2 increases risk of early onset breast cancer

Two 1st degree relatives with BrCa1

Three or greater 1st or 2nd degree relatives (includes grandmothers, aunts) diagnosed with breast cancer

Both breast and ovarian cancer among 1st & 2nd degree relatives

A 1st degree relative diagnosed with cancer in both breasts

Two or more 1st or 2nd degree relatives

diagnosed with ovarian cancer A male relative with breast cancer

Overweight Alcohol use Remaining sedentary Delayed parity > 30 yrs or null-parity Recent OCP use Recent use of combined HRT after

menopause Long-term use of estrogen therapy

Monthy self breast exam (SBE)

Timely annualmammograms

Annual clinical breast exam (CBE)

Baseline mammogram for AA women by age 40

Annually for AA women 40 and older for as

long as they are in good health

If breasts are “lumpy” or risk factors exist, an earlier baseline may be useful

Begin age 20 with prompt reporting of any changes

Use pads of fingers to feel lumps

Check for fluid when nipples are squeezed

Check entire breast, armpits and collarbone area

Annual CBE demonstating SBE technique from age 20 onward. Discuss risk factors with patient during exam.

Document exam finding: “Breasts are symmetric. Skin is without inflammatory changes, erythema, dimpling, rash, color changes. Nipples without discharge. No palpable mass bilaterally.”

Skin changes with no palpable lump: Thickened peau l’orange texture, reddness, tenderness or rash

Although more white women are diagnosed with breast cancer, more black women die from the disease. An oncology referral for possible aggressive prevention for LCIS (+) or BRCA1&2 women may be necessary

Results from the Breast Cancer Prevention Trial (BCPT)2 have shown that women at high risk for breast cancer are less likely to develop the disease if they take TAMOXIFEN

Prophylactic mastectomy or oophorectomy may be indicated

National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

Helps low income, uninsured and underinsured women gain access to breast and cervical cancer screening and diagnostic services

cdc.gov/cancer/cbccedp Or, contact the Maryland DHMH for nearest screening center

Is committed to increasing local and national attention to the devastating impact that breast cancer has in the African American community.

www.sistersnetworkinc.org

In Baltimore:Dawn Fitzpatrick301.801.3512

baltimore@sistersnetworkinc.org

Is the 3rd most common cancer among African Americans

For reasons that are unknown, incidence rates for AAs are higher than for whites

Since 1989 incidence rates reversed and now African American men have higher rates than both white men and women

Similar to incidence rates, since 1985, mortality rates have risen steadily and are higher in African Americans than in whites

5-year survival rate improvements since 1999 have slowed as compared to whites in each stage of diagnosis

Life Style ◦ Physical inactivity◦ Obesity◦ High consumption red and processed meat◦ Smoking6

◦ Excessive alcohol use

Non-Modifiable Risk Factors◦ Increasing age◦ Personal or family history of cancer or adematous

polyps before age 55◦ Personal history of Inflammatory Bowel Disease◦ Family history of Lynch syndrome or familial

adenomatous polyposis

The Other Risk Factor:

Tests that find polyps and cancer◦ Colonoscopy◦ Flexible sigmoidoscopy◦ Double-contrast barium enema◦ DRE◦ CT colonography (virtual colonoscopy)

Tests that find mainly cancer◦ Fecal occult blood test (FOBT)◦ Fecal immunochemical test (FIT)◦ Stool DNA test (sDNA)

Patients who are at moderate or high risk for colorectal cancer should have screenings earlier

ADVANTAGES DISADVANTAGES

Gold Standard

Examines entire colon

Can biopsy and remove polyps

Can diagnose other diseases

Required for abnormal results from all other abnormal tests

Can miss some polyps and cancers

Full bowel prep needed

Can be expensive

Sedation of some kind needed; necessitating a chaperone

May miss day of work

Higher risk of tears and/or bowel infections as compared to other tests

ADVANTAGES DISADVANTAGES

Fairly quick

Few complications

Minimal bowel prep

Minimal discomfort

Does not require sedation or a specialist

Views only 1/3 of colon

Bowel prep needed

Cannot remove large polyps

Small risk of infection or bowel tear

Slightly more effective when combined with FOBT

Colonoscopy necessary if abnormalities detected

ADVANTAGES DISADVANTAGES

Can usually view entire colon

Few complications

No sedation needed

Can miss some small polyps and cancers

Full bowel prep needed

Cannot remove polyps

Exposure to low dose radiation

Colonoscopy necessary if abnormalities detected

ADVANTAGES DISADVANTAGES

Examines entire colon

Fairly quick

Few complications

No sedation needed

Noninvasive

Can miss some polyps and cancers

Full bowel prep needed

Cannot remove polyps

Exposure to low dose radiation

Can be expensive

Colonoscopy necessary if abnormalities detected

ADVANTAGES DISADVANTAGES

No bowel prep

Sampling is done at home

Low cost

Non-invasive

May require multiple stool samples

Will miss most polyps and some cancers

Higher rate of false positives than other tests

Pre-test dietary limitations*

Colonoscopy necessary if abnormalities detected*Dietary restrictions such as avoiding meat, certain vegetables, vitamin

C, iron supplements, and aspirin, and increasing fiber consumption, are often recommended for several days before a guaiac FOBT. These restrictions are not required for immunochemical FOBT.

http://www.youtube.com/watch?v=CKFs-gfiwPM

A youtube video diary of Steve Harvey as he undergoes a colonoscopy.Produced by the AMS

Colorectal Cancer Control Program (CRCCP)◦ Provides early detection tests for ages 50-64 yrs

who are under-insured or uninsured.

Cdc.gov/cancer/crccp or 1 (800) 477-9774

Maryland Colorectal Cancer Control Program Maryland Department of Health and Mental HygieneCenter for Cancer Surveillance and Control201 W. Preston StreetBaltimore, MD 21201

Research suggests that African Americans are 55% more likely than whites to develop lung cancer from light to moderate cigarette smoking

The results hold true even after considering factors such as diet, socioeconomic status and occupations, suggesting that genetics and biology may play a role

Cancer of the lungs and bronchus is the 2nd leading cause of cancer in African Americans

The average incidence rate for cancers of the lung and bronchus during 2003-2007 was 23% higher in African American men than in white men.

Lung cancer kills more African Americans than any other cancer.

The disparity in lung cancer death rates between African American and white men has been substantially reduced overall (from an excess of 50% in 1990-1992 to 28% in 2003-2007) and has been eliminated in younger adults (under age 40).

The 5-year relative survival rate for lung cancer is lower in African Americans than in whites: 13% and 16%, respectively

When lung cancer is diagnosed early, African Americans are less likely than whites to receive surgery, the treatment with the best chance for cure, even after accounting for socioeconomic factors

Chest X-rays Sputum cytology Spiral (helical) CT scans of the lungs

Screening for lung cancer is usually done when symptoms present. However, results from the landmark National Lung Screening Trial (NLST), which indicate that screening with low-dose helical computed tomography (CT) reduces mortality from lung cancer, have been published in the New England Journal of Medicine.5

Maryland Quitline: Maryland DHMH1-800-QUIT-NOW or 1-877-777-6534http://www.smokingstopshere.com

Online resources and support. Directs visitor to local programs and groups:http://www.quitnet.com/qn_gizmo.jtml?q_feature=30http://www.smokefree.gov/tools.aspx

During the period 1960-1962, 42% of African American/black women were overweight, compared with 22% of African American/black men. By 2004, 76% of African American/black adults (20+) were overweight and 35% of the African American/black children were overweight and obese.

In 2005, African American/black high school students were less likely to meet current recommended levels of physical activity than non-Hispanic/Latino white students.

African American/black women, have the highest rates of

obesity in the nation, followed by Hispanic women and then non-Hispanic/Latina white women, who have about the same rates as white men.

Disparities can be improved by proper diet, daily physical activity, stopping smoking, health education & timely screenings for early detection

Body & Soul: Church–Based Health Program National Cancer Institute, National Institute

of Health, U.S. Department of Health and Human Services

Phone: 1-800-422-6237E-mail: contact@bodyandsoul.nih.gov

Women's Health Initiative (WHI) concluded that as little as 1.25 to 2.5 hours per week of brisk walking reduced a woman's risk by 18%. Walking 10 hours a week reduced the risk a little more8

UMMC/University of Maryland Greenbaum Cancer Center leads efforts to end racial disparities in cancer survival.

Over 153 clinical trials being conducted in the Baltimore Washington area

Call: 1-800-888-8823http://www.umgcc.org/trials_info/

ct_partic.htm

Studies show that incorporating a Spiritual message with the religiously involved African American has positive results3

“Behold, I have given you every herb bearing seed which is upon the face of all the earth, and every tree, in which is the,fruit of the tree yielding seed, to you it shall be for meat”. Genesis 1:29

“Whether therefore ye eat, or drink, or whatsoever ye do, do all to the glory of God”.I Corinthians 10:31

Mustard greens Collards Chard Strawberries Blueberries Blackberries Tomatoes Yams Okra Split peas Black-eyed peas

Fighting Cancer With Color!

The best diet for preventing or fighting cancer is a predominantly plant-based diet that includes a variety of vegetables, fruits, and whole grains.

* Five or more fruits and veggies a day * Whole grains instead of white flour or white rice * Limit high-fat meats & fried foods * Limit or eliminate processed meat (hot dogs, cold cuts, bacon) * Limit alcohol to 1-2 drinks per day

Foods high in folate may have some action against prostate cancer (spinach, orange juice, lentils). Studies found mixed results on lycopene, an antioxidant found in tomatoes

1) American Cancer Society. (n.d.) Cancer facts and figures for African Americans 2011-2012. Retrieved June 20, 2011 from http://www.cancer.org/Research/CancerFactsFigures/CancerFactsFiguresforAfricanAmericans/cancer-facts-figures-af-am-2011-2012

2) Elabbady, A. A., Khedr, M. M. (2006). Free/total PSA ratio can help in the prediction of high gleason score prostate cancer in men with total serum prostate specific antigen (PSA) of 3-10 ng/ml. International Urological Nephrology. 38 (3-4),553-537. Retrieved July 23, 2011 from http://www.ncbi.nlm.nih.gov/pubmed/17171424

3) Holt, C. L., Wynn, T. A. Litaker, M. S., Southward, P., Jeames, S. E., & Schultz E. K. (2009). A comparison of a spiritually based and non- spiritually based educational intervention for informed decision making for prostate cancer screening among church- attending African American men. Urology Nursing. 29(4), 249–58.

4) Intercultural Cancer Council. (n.d.) Cancer Facts – African Americans and Cancer. Retrieved July 21, 2011 from www.cancer.org/acs/groups/content/.../documents/.../acspc-027765.pdf

5) Mizoue, T., Inoue, M., Tanaka, K., Tsuji, I., Wakai, K., Nagata, C., & Tsugane, S. (2009). Tobacco smoking an colorectal cancer risk: an evaluation based on a systematic review of epidemiological evidence among the Japanese population. Japanese

Journal of Clinical Oncology. 36(1). 25-39. doi:10.1093/jjco/hyi207

6) Metcalfe, K. A., Narod, S. A., (2007). Breast cancer prevention in women with a BRCA1 or BRCA2 mutation. Open Medicine. 1 (3). Retieved July 23, 2011 from http://www.openmedicine.ca/article/view/11/100

7) National Cancer Institute. (n. d.) The Breast Cancer Prevention Trial. Retrieved June 28, 2011 from http://www.cancer.gov/clinicaltrials/noteworthy-trials/bcpt/Page1

8) National Institutes of Health (n.d.). Women’s Health Initiative - WHI In dbGAP. Retieved July 22 2011 from http://www.nhlbi.nih.gov/whi/

9) Walker, H. K., Hall, W. D., Hurst, J. W., (1990). Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston, MA. Butterworths Publishers.

10) Yokomizo, Y., Miyoshi, Y., Nakaigwa, N., Makiyama, K., Ogawa, T., Yao, M., Kubota, Y., & Uemura, H. (2009). Free PSA/total PSA ratio increases the detection rate of prostate cancer in twelve-core biopsy. Urology International. 82(3). 280-285. Retrieved July 23, 2011 from http://www.ncbi.nlm.nih.gov/pubmed/19440014