Category Archives: Prostate Cancer

Racial Differences in Prostate Cancer

Meg Seymour, PhD: National Center for Health Research


About 13% of men will develop prostate cancer during their lifetime, and about 2-3% of men will die from it.[1] After lung cancer, prostate cancer is the leading cause of cancer deaths in men[2], and older men are more likely to get prostate cancer then younger men.[1]

There are known racial differences as well: Black men are 1.5 times more likely to get prostate cancer than White or Latino men, and 3 times more likely to get prostate cancer than Asians and Pacific Islanders.[3,4] On average, Black men get prostate cancer a younger ages than other men, and their cancer is often more aggressive and more advanced when it is discovered.[1] Black men are also more than twice as likely to die from prostate cancer than men from other races.[1] 

This article will discuss the known racial differences in the screening, treatment, and outcomes of prostate cancer in the United States, as well as why these differences may exist. Note that many of the differences that have been studied compare Black and White men, and data about men from other races and ethnicities are more limited.

Differences in Screening

One of the main methods of screening for prostate cancer is a blood test that measures levels of prostate-specific antigen (PSA). PSA tests alone cannot tell if someone has cancer, but high levels of PSA might lead to further testing, like a biopsy. Another method of testing is the digital rectal exam, in which a doctor inserts a (gloved and lubricated) finger into a patient’s rectum to feel the prostate for bumps or hard areas, which might be cancer. 

As of 2018, the United States Preventive Services Task Force does not recommend prostate cancer screening for men ages 70 and over.[5] For men ages 55 to 69, they recommend that PSA screening should be an individual choice, based on factors such as family history or patient preference. For more information about prostate cancer screening and the recommendations for it, you can read this article.

If the results of a PSA test or digital rectal exam leads a doctor to suspect cancer, it can lead to a biopsy. A biopsy is when a small sample of tissue is removed and examined under a microscope for cancer cells.[6]

A 2017 article in a medical journal found that overall, non-Hispanic White men were slightly more likely to undergo PSA screening than Black men. This was a trend for the United States overall, but analysis by individual states showed that screening rates were actually higher for Black men in some states.[7] More recently, a 2020 study showed that between 2014 and 2018, Black men underwent prostate cancer screening at either a slightly lower rate than White men or at the same rate.[8] The study authors note that Black men need to be more intensively screened because they are more likely to get prostate cancer.  

A study presented at the 2021 meeting of the American Society of Clinical Oncology included over 4,000 Black men ages 40-55 who had been diagnosed with prostate cancer.[9] The study found that men who had an average of 3 PSA tests prior to their diagnosis were less likely to have metastatic disease than men who had an average of 0.5 PSA tests at the time of their diagnosis. Only 1.4% of the men who had been screened an average of 3 times had metastatic disease, compared with 4.2% of the men who had the least screening. Higher rates of PSA screening prior to diagnosis was also associated with a 25% reduction in the risk of dying from prostate cancer. The study suggests that more frequent PSA screening is associated with better outcomes among younger Black men.

Accuracy of screening also varied by race. A 2018 study found that although Black men were slightly more likely to have a false positive from their PSA screening, they were less likely to have a false positive from a digital rectal exam. Further, Black men were more likely than White men to have aggressive tumors and cancer that has metastasized, which means that it has spread to other body parts.[10] 

Differences in Treatment

There are numerous treatment options for prostate cancer, such as surgery, radiation, hormone therapy, and what are called watchful waiting and active surveillance. These treatment choices also vary by race.  

Active surveillance means that no specific treatment like surgery or a drug is used. Instead, a doctor closely monitors the cancer to see if it grows, using regular PSA tests, digital rectal exams, and biopsies. This option may be used if a man’s cancer is small, localized, or expected to grow slowly, so that he is not immediately treated with aggressive treatments that may have side effects.[11] Active surveillance is used for as many as 33% of men diagnosed with prostate cancer,[12] but it is not equally used among all men in the United States. A 2020 study found that although Black and White men receive active monitoring at the same rate, Hispanic men were less likely to receive it.[12] The researchers could not identify why this ethnic difference exists, but they noted that it could have to do with factors such as patient preferences or how often the option is offered by doctors.

Watchful waiting (also called observation) is slightly different from active surveillance. It involves less intensive follow-up, such as fewer tests. Instead, the patient’s doctor decides to wait and see if symptoms change. For many men, prostate cancer grows so slowly that a man might die of other causes before he would die of the cancer, so aggressive treatment is not needed. Treatments for prostate cancer can cause undesired side effects, such as incontinence and impotence, so many men may choose active surveillance or watchful waiting, if their cancer is considered low-risk enough.  

Definitive therapy refers to radiation treatment or surgical removal of the prostate. Both procedures can have side effects such as erectile dysfunction and impotence.[13] A 2017 study looked at over 300,000 men who were diagnosed with localized prostate cancer and compared which men received definitive treatments, such as surgery, to which men received no treatment, such as men undergoing active surveillance. The study found that although White and Asian men received definitive treatment at about the same rate, Hispanic and Black men were less likely to receive it than White men were.[14] In the study, Black men with high risk prostate cancer were actually less likely to receive definitive therapy than White men with lower risk disease. Although Black men were likely to be on active surveillance, Black men on active surveillance are actually monitored less than White men on active surveillance. The researchers argue that Black men might be more likely than White men to benefit from definitive therapy, so they are concerned by the result that they are less likely to receive it. 

A 2016 study looked at surgical treatments for localized prostate cancer in men insured by Medicare. The researchers found that, on average, Black patients experienced a longer delay between diagnosis and treatment, and had more postoperative complications than White patients.[15] Research on men with metastatic prostate cancer has also found that Black men treated with the drugs docetaxel, abiraterone acetate, or enzalutamide have similar or even better outcomes to other men.[16] Researchers question why Black men have overall higher mortality rates from prostate cancer than other men. For example, is the higher death rate among Black men because they often have more advanced cancer when it is discovered, because their cancer is more aggressive, or because there is unequal access to treatments?

Why Do These Differences Exist?

Some people have suggested that racial differences in prostate cancer outcomes are because White men are, on average, of higher socioeconomic status than Black men. However, research has found that comparing men of the same socioeconomic status level, cancer screening was still more common among White men and detection of cancer was also earlier for White men.[17]

Researchers have suggested that differences in survival by race may be because Black men are more likely to be diagnosed at advanced stages of their cancer, when treatment options are more limited and can be less effective.[17] They are also more likely to have comorbid illnesses, such as diabetes and hypertension, which could affect survival rates.

A 2016 study found that, among men with localized prostate cancer, when researchers adjust for differences like at what stage a man’s cancer was diagnosed and what treatment he received, survival rates are equal across all races of men.[15] It is possible that the differences in cancer survival between races are due to racial differences in access to care.

There is an ongoing need for research into the causes of racial disparities in prostate cancer outcomes. 

The Bottom Line

Prostate cancer is a common form of cancer in men, and although it does not always need to be actively treated, it is one of the leading cancer killers. Black men are disproportionately affected. They are often diagnosed at younger ages, with more advanced stages of cancer, with more aggressive cancers, and they may be more likely to need screening. Further research is needed to understand the causes in racial differences in prostate cancer, but at least some of the differences in rates of survival between Black and White men may be due to differences in access to medical care.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

The National Center for Health Research is a nonprofit, nonpartisan research, education and advocacy organization that analyzes and explains the latest medical research and speaks out on policies and programs. We do not accept funding from pharmaceutical companies or medical device manufacturers. Find out how you can support us here.

References 

  1.     Centers for Disease Control and Prevention. Who Is at Risk for Prostate Cancer?. Cdc.gov. https://www.cdc.gov/cancer/prostate/basic_info/risk_factors.htm. Updated August 2020. 
  2.     Siegel DA, O’Neil ME, Richards TB, Dowling NF, Weir HK. Prostate Cancer Incidence and Survival, by Stage and Race/Ethnicity — United States, 2001–2017. MMWR Morbidity and Mortality Weekly Report. 2020;69:1473–1480. 
  3.     Borno H, George DJ, Schnipper LE, Cavalli F, Cerny T, Gillessen S. All men are created equal: addressing disparities in prostate cancer care. American Society of Clinical Oncology Educational Book. 2019 May 17;39:302-8.
  4.     Dobbs RW, Malhotra NR, Abern MR, Moreira DM. Prostate cancer disparities in Hispanics by country of origin: a nationwide population-based analysis. Prostate Cancer and Prostatic Diseases. 2019 Mar;22(1):159-67.
  5.     Fenton JJ, Weyrich MS, Durbin S, Liu Y, Bang H, Melnikow J. Prostate-specific antigen–based screening for prostate cancer: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018 May 8;319(18):1914-31.
  6.     American Cancer Society. Tests to Diagnose and Stage Prostate Cancer. Cancer.org. https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/how-diagnosed.html. Updated December 2020. 
  7.     Jindal T, Kachroo N, Sammon J, Dalela D, Sood A, Vetterlein MW, Karabon P, Jeong W, Menon M, Trinh QD, Abdollah F. Racial differences in prostate-specific antigen–based prostate cancer screening: state-by-state and region-by-region analyses. Urologic Oncology: Seminars and Original Investigations. 2017; 35(7):460-e9. 
  8.     Kearns JT, Adeyemi O, Anderson WE, Hetherington TC, Taylor YJ, Zhu J, Burgess EF, Gaston KE. Contemporary racial disparities in PSA screening in a large, integrated health care system. 2020; 38(6): 308-308. 
  9.   Bassett M. Vaccination, Screening Succeeds in Cervical and Prostate Cancers. MedPageToday. https://www.medpagetoday.com/meetingcoverage/asco/92688. May 19, 2021. 
  10.     Miller EA, Pinsky PF, Black A, Andriole GL, PierreVictor D. Secondary prostate cancer screening outcomes by race in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Screening Trial. The Prostate. 2018; 78(11):830-8.
  11. American Cancer Society. Observation or Active Surveillance for Prostate Cancer. Cancer.org. https://www.cancer.org/cancer/prostate-cancer/treating/watchful-waiting.html. Updated August 2019. 
  12. Washington SL, Jeong CW, Lonergan PE, Herlemann A, Gomez SL, Carroll PR, Cooperberg MR. Regional Variation in Active Surveillance for Low-Risk Prostate Cancer in the US. JAMA Network Open. 2020; 3(12):e2031349-.
  13. Tracy CR. Prostate Cancer Treatment & Management. Emedicine.medscape.com,. https://emedicine.medscape.com/article/1967731-treatment. Updated February 2, 2021. 
  14. Moses KA, Orom H, Brasel A, Gaddy J, Underwood III W. Racial/ethnic disparity in treatment for prostate cancer: does cancer severity matter?. Urology. 2017;99:76-83.
  15. Schmid M, Meyer CP, Reznor G, Choueiri TK, Hanske J, Sammon JD, Abdollah F, Chun FK, Kibel AS, Tucker-Seeley RD, Kantoff PW. Racial differences in the surgical care of Medicare beneficiaries with localized prostate cancer. JAMA Oncology. 2016;2(1):85-93.
  16. Hahn AW, Bilen MA, Agarwal N. Successful Recruitment of Black Men to Prostate Cancer Clinical Trials—A Lesson in Achievement. JAMA Network Open. 2021;4(1):e2034652-.)
  17. Di Pietro G, Chornokur G, Kumar NB, Davis C, Park JY. Racial differences in the diagnosis and treatment of prostate cancer. International Neurourology Journal. 2016;20(Suppl 2):S112.

Are Annual Prostate Cancer Screenings Necessary? Should Early Stage Prostate Cancer Be Treated?

By Krystle Seu, Dana Casciotti, PhD, Brandel France de Bravo, MPH, Mingxin Chen, MHS, and Nicholas Jury, PhD

Although usually not fatal, prostate cancer is second leading cause of cancer deaths for men in the United States, after lung cancer.[1] One in every eight men will be diagnosed with prostate cancer in his lifetime.1 Most cases are in men 65 and older, and most deaths occur in men 75 and older.2 Annual screenings would seem to be an important way to prevent prostate cancer.  But there is a hot debate within the medical community: Do routine prostate cancer screenings do more harm than good?

Should I Get Screened?

Diagnostic tests for prostate cancer are recommended for any man who has symptoms of prostate cancer, such as pain or changes in urination. Men over the age of 50 who have no symptoms sometimes undergo screening tests. In May 2012, the U.S. Preventive Services Task Force recommended against prostate-specific antigen (PSA) screening tests for men of any age.3 However, in May 2018, the Task Force revised their recommendation, stating that men ages 55-69 years old should talk to their doctor about the potential benefits and harms of PSA screening. The USPSTF continues to recommend against PSA screening in men ages 70 and older.4

What about other methods of screening, like digital rectal exams, which are usually done together with PSA testing? The Task Force continues to conclude that they tend to do more harm than good.

The U.S. Preventive Services Task Force is an independent group of medical professionals that reviews all evidence on preventive health care services. It adopted its current position after expressing doubts about the value of prostate cancer screening for several years. In 2008, the Task Force said screening was not recommended for men over 75, but wasn’t sure about its value for men younger than 75.5 In 2009, the American Urological Association issued new guidelines saying that annual screening was no longer recommended.6

The reason why these experts concluded that screening was rarely necessary is that prostate cancer grows very slowly.  Even without treatment, many men with prostate cancer will live with the disease until they eventually die of some other, unrelated cause.

Types of Prostate Cancer Screening: PSA Blood Tests and Digital Rectal Exams

Prostate cancer occurs when cells create small tumors in the prostate gland, which is an important part of the male reproductive system. Screening can be performed quickly and easily in a physician’s office using two tests: the prostate-specific-antigen (PSA) blood test, and the digital rectal exam (DRE), a manual exam of the prostate area.

Most screening tests are not 100% accurate, but these prostate tests are especially inaccurate.  Most men with a high PSA level (>4ng/mL) do not have prostate cancer (this is known as a false positive), and some men with prostate cancer have a low PSA level (this is called a false negative). The DRE also results in many false positives and false negatives. Using both screening methods together will miss fewer cancers but also increases the number of false positives, which can lead to more testing (usually biopsies of the prostate) and possibly result in medical complications. A biopsy to determine if there is a cancerous growth in the prostate involves inserting a needle, usually through the rectum, to remove a small sample of prostate tissue.

PSA Velocity

Researchers are also trying to determine if other types of PSA testing might be more accurate in detecting prostate cancer, such as changes in PSA levels when a man has multiple tests over time. The rate of change of PSA level from one test to the next is known as “PSA velocity.”

One study examined if PSA velocity could improve cancer detection compared to standard PSA and DRE screening tests.7 Because men with high PSA levels and positive DRE results typically undergo prostate biopsies to determine the presence of cancer, this study evaluated if PSA velocity helped detect cancer in men with low PSA and negative DRE results. Over 5,500 men were included in the study and men with high PSA velocity-almost 1 in 7 men-were biopsied. The researchers found that doing biopsies on the basis of high PSA velocity in the absence of a high PSA or positive DRE would lead to a large number of biopsies but would not improve cancer detection.

What Recent Research Tells Us About Prostate Cancer Screening

Depending on how often screening is done, it may help reduce the chances of dying of prostate cancer, but the research indicates that the vast majority of men with prostate cancer die of a different cause, even if they are not treated.

Two major research studies have tried to shed light on the value of regular screening: the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial and the European Randomized Trial of Screening for Prostate Cancer (ERSPC).8 The PLCO studied 76,000 men, aged 55-74, for 7-10 years and found that the death rate from prostate cancer was low, and that it did not differ between the men who were screened every year for the first six years of the study and those who received their usual care (which ranged from no screening to occasional screening).9 For most of the patients, “usual care” included at least one screening during the first seven years of the study. There were also no significant differences in overall death rates between the groups. Although the randomized portion of the study was completed in 2006, researchers are still studying the patients to see how long they live.10

The European study (ERSPC) included 182,000 men, ranging from 50 to 74 years old, from seven different European countries.11 In these countries, “regular screening” is usually every 4 years, although it is every 2 years in Sweden. Those men were compared to men of the same age who did not get any prostate cancer screening. After the men were studied for an average of 13 years, the researchers found that the patients who had PSA screening were 27% less likely to die of prostate cancer.8 However, they did not live longer than the other men, because they died of other causes.

A follow-up to the ERSPC study, which tracked the men for an average of 11 years, found an even greater reduction in prostate cancer deaths-29% over the longer follow-up period.12 To prevent 1 death from prostate cancer, the program needed to screen 1,055 men and treat 37 men.  More important, although deaths from prostate cancer were lower in the PSA screened group, there were no differences in overall mortality between the two groups.  In other words, the PSA screening reduced deaths from prostate cancer but those men were more likely to die from other causes.

Recent updates to a 2010 meta-analysis (which means researchers “pooled” data from many different but comparable studies) of six randomized, controlled prostate cancer screening trials (including the PLCO and ERSPC studies) further support the U.S. Preventive Services Task Force recommendations. Analysis of data on almost 330,000 men showed no significant difference in the risk of death from prostate cancer between the men who received PSA screenings and those who did not.13

A United Kingdom study published in 2018 in the prestigious medical journal JAMA involved over 160,000 men between the ages of 50 to 59 years. The study found that a one-time PSA screen increased the chances of diagnosing prostate cancer, but did not change the chances of dying from prostate cancer. Over a 10-year period, about 4.3% of men who had a one-time PSA test were diagnosed with prostate cancer compared to about 3.6% of men who did not have a PSA screen. The one-time PSA screen was able to detect prostate cancers that were lower grade and less likely to be dangerous.

Importantly, there was no evidence that having a PSA screen test saved lives. In men who were diagnosed with prostate cancer, the chances of dying from the prostate cancer within 10-years of diagnosis were about 3 in 10,000 (that’s less than half of a percent), and that was the case whether the men had a PSA screening or not. This means that a PSA test may detect more prostate cancers, but these are likely cancers that would not have been harmful. This study does not show that one-time screening with PSA would be helpful, and it could be harmful. The researchers have planned to look at these issues more closely in a longer term study.14

Benefits and Harms of Screening

The benefit of screening is that the disease is often curable with early detection (90% or better).  Common treatments like surgery or radiation aim to remove or kill all cancerous cells in the prostate.  If the cancer spreads beyond the prostate before it is treated, it is often fatal.  However, the cancer usually grows so slowly that it is often equally safe to wait until there are symptoms before attempting to diagnose prostate cancer. Symptoms of prostate cancer might include urinary problems, difficulty having an erection, or blood in the urine or semen.

The harms of screening include 1) inaccurate results leading to unnecessary biopsies and complications, and 2) complications from unnecessary treatment. Even if a man has prostate cancer, if he does not have symptoms he may not need to be treated. Experts estimate that between 18% and 85% of prostate cancers detected by these screening tests would never become advanced enough to harm the patient.  This wide range of uncertainty, however (is it less than 1 out of 5 or more than 4 out of 5?) just adds to the confusion.

Unnecessary treatment costs a lot of money, but the main concern is the complications, which include serious and long-lasting problems, such as urinary incontinence and impotence.15

Long before the Task Force made its recommendation, many doctors and patients questioned whether annual prostate cancer screenings were a good idea, since the disease is rarely fatal. Many also question whether treating early prostate cancer, the kind of prostate cancer screening tests mostly find, is a good idea. Treating early prostate cancer does not appear to help men live longer, and for many it drastically reduces their quality of life.

Doctors and scientists are searching for better tests for prostate cancer detection. Many experts believe that a family history of prostate cancer or other cancers should influence how often a man chooses to get PSA screening.  However, the studies described below, which led to the Task Force’s recommendation against PSA screening, suggest that annual screenings for all men are not a good idea.

Is Surgery Effective for Men with Early-Stage Prostate Cancer?

When they hear the word “cancer,” many men want it treated immediately no matter how slow it is growing or how unlikely it is to be fatal. The question is: if found in its early stages, should prostate cancer be treated?

In July 2012, a study by researchers at the Department of Veterans Affairs was published in the New England Journal of Medicine, examining the effectiveness of surgery in men with early-stage prostate cancer.16 Known as the Prostate Cancer Intervention versus Observation Trial, or PIVOT, the study compared surgical removal of the prostate with no prostate cancer treatment. The 731 men who participated in the study, with an average age of 67, were randomly assigned to one of the two groups and followed for 8 to 15 years. All the men were enrolled between 1994 and 2002, with a final check-up taking place in 2010. Men in both groups went to the doctor every six months during the study, and men in the observation-only group were offered palliative therapy (which focuses on reducing suffering) or chemotherapy to relieve symptoms due to the cancer spreading to other parts of the body. Neither therapy can eliminate the cancer and, therefore, are not treatments.

The findings suggest that prostate cancer surgery does not save the lives of men with early-stage prostate cancer. Only 7% of the participants died of prostate cancer or from treatment during the study: 21 or 5.8% of those had their prostate removed and 31 (8.4%) who did not undergo surgery. The difference between the surgery and observation groups was not statistically significant, which means that the smaller number who died in the surgery group could have been due to chance. The prostate cancer spread to the bone in 4.7% of the surgery patients and to 10.6% of the observation or no-treatment group. Even when cause of death wasn’t limited to prostate cancer, the two groups died at about the same rate: 47% of the men who had surgery died during the study period as compared with 50% in the observation group.

The only men who benefited from the surgery were those with a PSA of 10 ng per milliliter or higher and men with riskier tumors: their overall risk of dying during the study period-not necessarily from prostate cancer-was lower than in the observation group. Surgery reduced the risk of dying from any cause by 13.2% among men with a PSA of 10 ng per milliliter or higher. For men with intermediate risk tumors (determined by a PSA value of 10.1 to 20.0 ng per milliliter, a score of 7 on the Gleason scale, or a stage T2b tumor), surgery reduced their risk of dying by 12.6%, but for men with high risk tumors, the reduction in risk by 6.7% was not statistically significant. That means it could have happened by chance.

In September 2016, the prestigious New England Journal of Medicine published a 10-year study by researchers from University of Oxford, which provided solid evidence that neither surgery nor radiation treatments save lives.17 The study compared the death rates of three patient groups: surgery, radiation, and active monitoring, which is sometimes called active surveillance. Between 1999 and 2009, the study randomly assigned 1643 men with diagnosed prostate cancer to the three groups to receive radical surgery (553 men), radical radiotherapy (545), or active monitoring (545). Unlike the PIVOT study, patients in the “active monitoring group” underwent tests to determine if their prostate cancer had progressed; these were conducted every 3 months for the first year, and every 6 to 12 months after that. The patients had an average (median) of 10 years of follow-up.

At the final check-up, 169 men had died, and there was no significant difference among the three groups of prostate cancer patients. Only 17 of these were deaths from prostate cancer: 5 in the surgery group, 4 in the radiotherapy group, and 8 in the active-monitoring group. However, prostate cancer was more likely to progress or spread in the group of men who were monitored rather than treated.

This study was the first to compare the effectiveness of surgery, radiotherapy and active monitoring. The findings suggest that treatment does not improve the chances of a man living longer, since most of the men will be dying of other causes rather than prostate cancer. Since prostate cancer treatment can cause serious side effects such as erectile dysfunction and incontinence, active monitoring is now recognized as a reasonable option. In fact, due to studies like this, active monitoring (also called active surveillance) is considered the preferred option for most men with low-risk prostate cancer.18 The number of men in the United States who receive active monitoring instead of active treatment has been increasing in recent years. In 2010, only 13% of men with prostate cancer received active monitoring, compared to 33% of men in 2015. 

However, a 2020 study of over 80,000 men with low risk, localized prostate cancer found that active monitoring is not equally common across all regions of the United States and across all men.18 Men with Medicaid, as well as men living in counties where fewer residents have a college education, were less likely to receive active monitoring. Although rates of active monitoring were the same for Black and White men, the study found that Hispanic men were less likely to receive it. The researchers could not identify why this ethnic difference exists, but they suggested that it may be due to factors such as differences in how often the option is offered by doctors and patients’ preferences. The study also found that single men were more likely to use active monitoring than married men.

Since prostate cancer treatment can cause serious side effects such as erectile dysfunction and incontinence, active monitoring seems to be a reasonable option.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

The National Center for Health Research is a nonprofit, nonpartisan research, education and advocacy organization that analyzes and explains the latest medical research and speaks out on policies and programs. We do not accept funding from pharmaceutical companies or medical device manufacturers. Find out how you can support us here.

References

  1. American Cancer Society. Key Statistics for Prostate Cancer. Cancer.org. https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html. Updated January 2021. 
  2. National Cancer Institute. Cancer Stat Facts: Prostate Cancer. Seer.cancer.gov. https://seer.cancer.gov/statfacts/html/prost.html
  3. Moyer VA. Screening for prostate cancer: US Preventive Services Task Force recommendation statement. Annals of Internal Medicine. 2012;157(2):120-34.
  4. Grossman DC, Curry SJ, Owens DK, Bibbins-Domingo K, Caughey AB, Davidson KW, Doubeni CA, Ebell M, Epling JW, Kemper AR, Krist AH. Screening for prostate cancer: US Preventive Services Task Force recommendation statement. JAMA. 2018 May 8;319(18):1901-13.
  5. Calonge N, Petitti DB, Dewitt TG, Dietrich AJ, Gregory KD, Harris R, Isham GJ, Lefevre ML, Leipzig R, Loveland-Cherry C, Marion LN. Screening for prostate cancer: US Preventive Services Task Force recommendation statement. Annals of Internal Medicine. 2008; 149(3):185-91.
  6. Greene KL, Albertsen PC, Babaian RJ, Carter HB, Gann PH, Han M, Kuban DA, Sartor AO, Stanford JL, Zietman A, Carroll P. Prostate specific antigen best practice statement: 2009 update. The Journal of Urology. 2009; 182(5):2232-41.
  7. Vickers AJ, Till C, Tangen CM, Lilja H, Thompson IM. An empirical evaluation of guidelines on prostate-specific antigen velocity in prostate cancer detection. Journal of the National Cancer Institute. 2011; 103(6):462-9.
  8. Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Zappa M, Nelen V, Kwiatkowski M, Lujan M, Määttänen L, Lilja H, Denis LJ. Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. The Lancet. 2014; 384(9959):2027-35.
  9. Andriole GL, Crawford ED, Grubb III RL, Buys SS, Chia D, Church TR, Fouad MN, Gelmann EP, Kvale PA, Reding DJ, Weissfeld JL. Mortality results from a randomized prostate-cancer screening trial. New England Journal of Medicine. 2009; 360(13):1310-9.
  10. National Cancer Institute. Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO). Prevention.cancer.gov. https://prevention.cancer.gov/major-programs/prostate-lung-colorectal-and-ovarian-cancer-screening-trial.
  11. Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, Kwiatkowski M, Lujan M, Lilja H, Zappa M, Denis LJ. Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine. 2009; 360(13):1320-8.
  12. Schröder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, Kwiatkowski M, Lujan M, Lilja H, Zappa M, Denis LJ. Prostate-cancer mortality at 11 years of follow-up. New England Journal of Medicine. 2012; 366(11):981-90.
  13. Djulbegovic M, Neuberger MM, Dahm P. Prostate-cancer mortality after PSA screening. The New England Journal of Medicine. 2012; 366(23):2228-9.
  14. Barry MJ. Screening for prostate cancer: is the third trial the charm?. JAMA. 2018; 319(9):868-9.
  15. Sanda MG, Dunn RL, Michalski J, Sandler HM, Northouse L, Hembroff L, Lin X, Greenfield TK, Litwin MS, Saigal CS, Mahadevan A. Quality of life and satisfaction with outcome among prostate-cancer survivors. New England Journal of Medicine. 2008; 358(12):1250-61.
  16. Wilt TJ, Brawer MK, Jones KM, Barry MJ, Aronson WJ, Fox S, Gingrich JR, Wei JT, Gilhooly P, Grob BM, Nsouli I. Radical prostatectomy versus observation for localized prostate cancer. New England Journal of Medicine. 2012; 367:203-13.
  17. Hamdy FC, Donovan JL, Lane J, Mason M, Metcalfe C, Holding P, Davis M, Peters TJ, Turner EL, Martin RM, Oxley J. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. New England Journal of Medicine. 2016; 375:1415-24.
  18. Washington SL, Jeong CW, Lonergan PE, Herlemann A, Gomez SL, Carroll PR, Cooperberg MR. Regional Variation in Active Surveillance for Low-Risk Prostate Cancer in the US. JAMA Network Open. 2020; 3(12):e2031349-.

Pomegranate Juice and Prostate Health

Laura Covarrubias, Cancer Prevention and Treatment Fund

Pomegranate juice contains plenty of antioxidants, but does it improve health, as the ads imply? Pom Wonderful, a large company that makes pomegranate juice and other products from pomegranates, would like you to believe that the juice can prevent or treat a number of health problems, including prostate cancer and erectile dysfunction. However, a close look at the science behind these claims shows that drinking pomegranate juice to treat or prevent prostate cancer and erectile dysfunction might not be worth the cost or the calories.

Prostate cancer is the most common cancer among men, other than skin cancer. (For more on skin cancer, read Tanning Beds: Safe Alternative to Sun? and Running and Skin Cancer Prevention.) Since almost everyone knows someone with prostate cancer, and since treatments can cause erectile dysfunction and incontinence, there is a tremendous desire to find a way to prevent the disease.

Even among men who have not had prostate cancer, erectile dysfunction-the inability to have or maintain an erection (called “ED” in advertisements)-is common. Many men suffering from erectile dysfunction want treatments that are less expensive and more natural than Viagra and other prescription medications.

Drinking pomegranate juice has been touted as an easy solution to decreasing the risk of prostate cancer and improving erectile dysfunction, but does it work? Nearly all of the studies are sponsored by Pom Wonderful, which is selling the products that the studies are evaluating. The company reports having spent at least $35 million on the research; unfortunately, studies sponsored by a product’s manufacturer tend to be biased in favor of the products.[1]

A May 2012 ruling by the Federal Trade Commission (FTC) concluded that Pom Wonderful’s promotional materials about the health benefits of their products are misleading and that their claims that pomegranate juice can treat, prevent, or reduce the risk of certain health conditions (including prostate cancer, erectile dysfunction, and heart disease) were deceptive.[2] Because of federal laws against making misleading disease prevention and treatment claims, the court issued a cease-and-desist order to Pom Wonderful. While the ruling prohibits Pom Wonderful from promoting its juice as a treatment for prostate cancer or erectile dysfunction, it doesn’t prevent the company from making broad claims about pomegranate juice such as that it “promotes prostate health.”

What the Science Says about Prostate Cancer and Pomegranate Juice

Only one study has been published in a peer-reviewed medical journal that looks at the effect of drinking pomegranate juice on prostate cancer. This 2006 study, funded by Pom Wonderful, is often used by the company to back its claims that their juice can help fight prostate cancer.[3] Only 46 men treated with either surgery or radiation for prostate cancer participated. All the men had rising prostate-specific antigen (PSA) levels, which is interpreted as a sign that their prostate cancer had come back, and all were given 8 ounces of Pom Wonderful to drink daily for a period of two years. The study found that the men’s rising PSA levels slowed, which can mean that their cancers were no longer growing as fast. To read more about PSA tests, click here.

In most scientific research, some patients receive a new treatment and the others receive either a placebo (sugar pill) or an older treatment. The Pom study was poorly designed because all the men drank the juice, making it impossible to evaluate the impact of the juice. Since PSA levels vary over time, we can’t know if PSA levels dropped because of the juice or would have dropped even without the juice.  In addition, the study only evaluated 46 men, all of whom had been treated for prostate cancer.  This small number of prostate cancer patients is not large enough to draw conclusions about all men, or even all men who have been treated for prostate cancer.

This 2006 study also looked at samples of cancer cells that were taken from other men with prostate cancer-not the same men who drank the pomegranate juice. These cancer cells were then treated with serum – a component of blood – from the men who drank pomegranate juice to see if the cancer cells stopped growing. The study found that cancer cells died when treated with the serum.  That sounds impressive, but there are many reasons why the serum could have caused the cancer cells to die. The researchers called for a future study with a control group (where cancer cells are treated with nothing), but six years later no study like that has been published.

Studies of pomegranate juice on mice and on human cells were more promising, but also not conclusive. One study funded by the U.S. Public Health Service, a government agency, looked at the effect of pomegranate extract – a very concentrated form of pomegranate juice – on prostate cancer cells that were taken from patients but grown outside of the body.[4] They found that the growth of cancer cells treated with the pomegranate extract was slower in comparison to the cancer cells not treated with the extract. In this same study, scientists also looked at the effects of pomegranate extract on the tumor size of mice with prostate cancer. They saw that the growth rate of the tumors in mice treated with the extract was slower in comparison to the growth rate of tumors in the mice that were not treated.

Another laboratory study found that more prostate cancer cells died in the samples treated with pomegranate juice concentrate provided by Pom Wonderful than in samples treated with different types of pomegranate extract.[5] The researchers believe that the many different chemical compounds in pomegranate juice work together to kill cancer cells, and that the pomegranate extract did not have all of these compounds and so did not have as strong of an effect. However, this study does not tell us if drinking pomegranate juice-rather than applying it to cancer cells-can prevent or treat cancer.  Even if there were research indicating a benefit from drinking the juice, how much juice would men have to drink?

Pom has also funded studies on clogged arteries and diabetes, which required people to drink 8 ounces of pomegranate juice every day (these studies were also inconclusive about the effects of pomegranate juice).[6,7] Even if 8 ounces a day was effective at lowering prostate cancer risk or improving health, this is a solution that not everyone could afford.  The cost of the juice, which would not be covered by health insurance, would be about $780 a month.[8] Drinking 8 ounces of Pom Wonderful adds an additional 160 calories per day, which equals 1,120 calories a week and 4,800 calories a month.  Unless the juice replaces an equally caloric drink, this could increase a person’s weight, which in turn increases the risk of prostate cancer and several other types of cancer (Weight and Cancer: The Latest Research).

What other alternatives are there?  Diets high in fiber and low in meat products and saturated fats have been linked to a lower risk of prostate cancer in men, and these diets also have other positive health effects such as reducing the risk of developing diabetes, heart disease, and stroke.[9,10,11] To learn more about the connections between diet and prostate cancer, read here.

What the Science Says about Erectile Dysfunction and Pomegranate Juice

There is even less evidence behind Pom Wonderful’s claims that drinking pomegranate juice decreases erectile dysfunction than there is about prostate cancer or other illnesses. Two studies used by Pom Wonderful to back these claims were conducted on rabbits – not humans.[12,13]These studies found that antioxidants (not pomegranate juice specifically) may be useful against erectile dysfunction, although no definite conclusions were made even for rabbits, and certainly not for humans.

The only study of humans used by Pom Wonderful divided the 53 participants with erectile dysfunction into two groups.[14] One group was assigned to drink pomegranate juice every day for the first 28 days, while the other group drank a placebo drink. After 28 days, the men answered questions about their erectile function. For the next two weeks, both groups stopped drinking their assigned drink (juice or placebo) – this time is known as a “washout” period. Research studies use washout periods to make sure that any effects of the treatment do not continue to be measured when the person begins drinking the new drink. After the washout period, the groups switched drinks so that the group that drank pomegranate juice drank the placebo for 28 days (and vice versa). Again, the men answered the same questions about their erectile function. Overall, the researchers did not find any statistically significant difference between the two groups.  Although there was a slight decrease in erectile dysfunction among the men drinking the pomegranate juice, the difference was small and could have occurred by chance. The researchers called for a larger and longer study to determine if pomegranate juice really does improve erectile dysfunction. We agree.

More Research Needed

Better research on men is needed to determine if regularly drinking pomegranate juice or taking pomegranate extract pills prevents or helps treat prostate cancer, erectile dysfunction, or other conditions. In the meantime, there is no harm in drinking pomegranate juice as long as it does not contribute to overweight or obesity.  Men who choose to drink pomegranate juice should consider the extra calories and cost.

Bottom Line:

  • There is no strong evidence to support the claim that pomegranate juice protects against prostate cancer or helps with erectile dysfunction.
  • Age increases the likelihood of prostate cancer and erectile dysfunction, and weight gain can also increase the chances of getting prostate cancer or having it return after treatment.[15]
  • If you or a loved one is undergoing treatment for prostate cancer, pomegranate juice is not an effective alternative.

References:

  1. Lexchin J, Bero L, Djulbegovic B. Pharmaceutical industry sponsorship and research outcome and quality: systematic review. Bmj. 2003;326(May). Available at: http://www.bmj.com/content/326/7400/1167.short. Accessed June 6, 2012.
  2. United States of America Federal Trade Commission. Initial Decision. 2012. Available at: http://www.ncbi.nlm.nih.gov/pubmed/1245105.
  3. Pantuck AJ, Leppert JT, Zomorodian N, et al. Phase II study of pomegranate juice for men with rising prostate-specific antigen following surgery or radiation for prostate cancer. Clinical cancer research : an official journal of the American Association for Cancer Research. 2006;12(13):4018-26. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16818701. Accessed March 28, 2012.
  4. Malik A, Afaq F, Sarfaraz S, et al. Pomegranate fruit juice for chemoprevention and chemotherapy of prostate cancer. Proceedings of the National Academy of Sciences of the United States of America. 2005;102(41):14813-8. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1253570&tool=pmcentrez&rendertype=abstract.
  5. Seeram NP, Adams LS, Henning SM, et al. In vitro antiproliferative, apoptotic and antioxidant activities of punicalagin, ellagic acid and a total pomegranate tannin extract are enhanced in combination with other polyphenols as found in pomegranate juice. The Journal of nutritional biochemistry. 2005;16(6):360-7. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15936648. Accessed May 24, 2012.
  6. Aviram M, Rosenblat M, Gaitini D, et al. Pomegranate juice consumption for 3 years by patients with carotid artery stenosis reduces common carotid intima-media thickness, blood pressure and LDL oxidation. Clinical nutrition (Edinburgh, Scotland). 2004;23(3):423-33. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15158307. Accessed May 2, 2012.
  7. Rosenblat M, Hayek T, Aviram M. Anti-oxidative effects of pomegranate juice (PJ) consumption by diabetic patients on serum and on macrophages. Atherosclerosis. 2006;187(2):363-71. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16226266. Accessed May 13, 2012.
  8. United States of America Federal Trade Commission. Initial Decision. 2012. Available at: http://www.ncbi.nlm.nih.gov/pubmed/1245105.
  9. Cohen JH, Kristal a R, Stanford JL. Fruit and vegetable intakes and prostate cancer risk. Journal of the National Cancer Institute. 2000;92(1):61-8. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10620635.
  10. Ma RW-L, Chapman K. A systematic review of the effect of diet in prostate cancer prevention and treatment. Journal of human nutrition and dietetics : the official journal of the British Dietetic Association. 2009;22(3):187-99; quiz 200-2. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19344379. Accessed June 10, 2012.
  11. Anderson JW, Baird P, Davis RH, et al. Health benefits of dietary fiber. Nutrition reviews. 2009;67(4):188-205. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19335713. Accessed March 3, 2012.
  12. Azadzoi KM, Schulman RN, Aviram M, Siroky MB. Oxidative stress in arteriogenic erectile dysfunction: prophylactic role of antioxidants. The Journal of urology. 2005;174(1):386-93. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15947695. Accessed July 16, 2012.
  13. Zhang Q, Radisavljevic ZM, Siroky MB, Azadzoi KM. Dietary antioxidants improve arteriogenic erectile dysfunction. International journal of andrology. 2011;34(3):225-35. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20584092. Accessed July 16, 2012.
  14. Forest CP, Padma-Nathan H, Liker HR. Efficacy and safety of pomegranate juice on improvement of erectile dysfunction in male patients with mild to moderate erectile dysfunction: a randomized, placebo-controlled, double-blind, crossover study. International journal of impotence research. 2007;19(6):564-7. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17568759. Accessed July 16, 2012.
  15. Kaluza J, Wolk A, Larsson SC. Red Meat Consumption and Risk of Stroke: A Meta-Analysis of Prospective Studies. Stroke; a journal of cerebral circulation. 2012. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22851546. Accessed August 9, 2012.