Sunday, December 17, 2006

Racial Disparities Are Not The Principal Factors In Understanding Why Black Men Have Advanced Stage Diagnosis Of Prostate Cancer- Priya Desai

Introduction: The Issue At Hand
Prostate cancer is the most frequently diagnosed visceral cancer and the second leading cause of cancer death in men. The American Cancer Society estimated that 184,500 new cases were diagnosed in 2000 and that the morbidity and mortality rates are significantly elevated among black americans. They are less likely to be screened for prostate cancer than whites and more likely to have advanced disease at the time of diagnosis (Ashford, 2001).

Prostate cancer screening is controversial because the combination of the disparities in incidence, mortality, and five year survival rates with the uncertain benefits associated with screening poses a difficult decision for black American men (Hoffman, 2001). There are a number of explanations that have been proposed to account for the advanced stage diagnosis of prostate cancer in black men. For example, demographic characteristics, socioeconomic status, level of education, and comorbidity may limit cancer screening in the black American population and possibly contribute to a delayed diagnosis. This paper argues that these factors, while important, are not the only reasons for advanced stage diagnosis. The issues of race, within the broader context of social power relations, are vital to understanding why such a disparity exists. Perhaps, as a legacy of racism, black Americans’ distrust invasive diagnostic and therapeutic procedures and this inhibits them from seeking or accepting this type of care. Given that black men are at such high risk for prostate cancer, it is imperative that interventions be made to shift the focus toward a greater emphasis on the cultural and behavioral attitudes, beliefs, and lifestyle patterns of black men to better understand the delays in prostate cancer screening.

Historical Influence on Black American Perspective of The Medical Community
Before examining the methods of prostate cancer screening, the historical context shaping the black American perspective of the biomedical community should be addressed. Gamble (1997) describes the Tuskegee Syphilis Study as the principal reason behind the black communities’ distrust of the institutions of medicine and public health. After the study had been exposed, charges of black genocide surfaced. Many blacks believed that this was a government plot for racial extermination. The biggest fear is that they will become victims of some misfortune like the Tuskegee incident where black men were infected with syphilis and left untreated to die of the disease. The cultural impact of this study explains several factors that have influenced and continue to impact black americans’ thoughts on the biomedical community. Fears about exploitation by the medical profession date back to when slaves and free black people were used as subjects for dissection and medical experimentation (Gamble, 1997). Slaves were used as subjects for medical experiments because physicians needed bodies to practice newly acquired surgical skills such as hysterectomies and caesarians. The state viewed the subjects as property and they could not refuse to participate (Gamble, 1997).
Feelings of paranoia, distrust, and anxiety after Tuskegee still resonate in the black American community. As a result, black people are cautious when interacting with the medical profession because sentiments of having been a guinea pig and the fear of potentially becoming a guinea pig still plague them. This leads to beliefs that they are devalued by white society and this exacerbates the contentious relationship they have with the medical profession (Corbie-Smith, 1999).

Beyond Tuskegee, revelations of about a measles vaccine financed by the Centers for Disease Control and Prevention (CDC) demonstrate that medical racism and exploitation of black people are evident as recent as 1991. In 1989 in the midst of a measles epidemic in Los Angeles, the CDC began a study to test whether the experimental Edmonston Zagreb vaccine could be used to immunized children to young for the standard vaccine. The experimental vaccine was given to both hispanic and black infants. After the 1996 disclosure of the study, it was found that the parents had not been informed that the vaccine was not licensed in the United States or that it had been associated with an increase in death rates in Africa. This further fueled the negative perspective of medical professionals in black American culture (Gamble, 1997).

Screening Behavior influenced by Social Systems
The challenge facing interventions for prostate cancer screening is to deviate from the focus of educational and socioeconomic disparities as explanations for advanced stage diagnosis in black men (Chan et al, 2003). Health initiatives will be more successful if they are informed by cultural competence and health literacy issues (Cowart, 2004). As illustrated, historical aspects contribute to the black communities’ perceptions of the medical profession. This further extends to negative perceptions of the physician and the hospital. Hospitals are primarily looked upon as “white institutions,” while physicians are seen as white researchers motivated by their drive for money, status and prestige (Corbie-Smith et al, 1999). Being predisposed to these health beliefs and perceptions influence the behavior of black men towards prostate cancer screening.

Emile Durkheim believed that social systems and human behavior are not mutually exclusive, but human behavior is influenced by social systems (Plowden et al, 2002). In a study looking at prostate cancer knowledge, attitudes, and screening behavior among African-Americans in central Harlem, black men were more likely to seek care when a supportive environment existed along with significant encouragement (Ashford et al, 2001). To understand individuals’ behaviors, it is necessary to understand the social structure. Within this structure are networks that hold individuals together and create values and norms. Based on this viewpoint, health beliefs (negative and positive) are transferred within the group and affect behavior. In the black community, fatalism is a barrier to seeking healthcare. Black men are less likely to believe that they can control the outcome of prostate cancer (Ashford et al, 2001). These beliefs have been passed from generation to generation and are a result of the social structure.

This distrustful perspective of the medical profession, heavily influences the decisions to be screened for early cancer detection. In a study conducted by Woods et al., descriptive quantitative findings of a mixed–method longitudinal assessment explored prostate cancer screening behaviors among 277 black men. The participants in the study viewed cultural competence as a sign of acceptance of black values and an openness of having blacks connected to the health system in a meaningful and respectful manner (Bhopal, 1998).

I believe there is a growing sense that health care providers do not take the time to meaningfully discuss the implications of prostate cancer. Lack of qualitative discussion by the physician about prostate cancer implies the cancer is not an important issue among black men or that there is a strong cultural barrier that precludes quality of care. Research has shown that this is particularly true in discordant patient/physician relationships. For example in a study conducted by Woods et al. (2004) focusing on culture, black men, and prostate cancer, participants were asked about their consult visits with non-black physicians at various sites in the United States. The participants believed that non-black physicians felt intimidated when asked questions about prostate cancer and individual prognosis. The participants felt this reaction was indicative of a negative global view of the black man. The historical dominant stereotype of black men in American society as the “thug,” “bad guy,” limits the chances of having a successful physician/patient relationship that reinforces black male understanding of prostate cancer (Woods et al, 2004).

The categorization theory further elucidates the idea that stereotypes are perpetuated when certain characteristics in a person belonging to a specific group are used to make generalizations of all members of that group. For example, if a black man is observed as being unreliable, and always late, a person may then generalize this to be true of all black men. This paradigm presents a conflict such that the profession of medicine possesses the ultimate authority in health related matters (Plowden et al, 2002). Health and illness may be viewed as professional constructs because organized medicine determines what constitutes disease, and practicing physician legitimize sickness claims through diagnostic process as well as access to treatment and screening tests. Thus, the medical profession not only defines disease in theory and identifies it in practice; it also supervises those who are sick. Plowden et al. (2002) have focused on black men and prostate cancer screening methods emphasizing that a caring, trusting, environment leads to an increased interest by black men and offers the potential to engage them in respectful relationships with their physicians. Public Health interventions have failed to encourage physicians to cultivate a positive relationship with their patients; especially black males who are know to mistrust the healthcare system. These efforts would help to strengthen the possibility of informed, and shared decision-making regarding prostate cancer early detection and screening.

Black American Male Perspective on Prostate Screening Methods
Studies have shown that black Americans’ distrust of invasive diagnostic and therapeutic procedures inhibits them from seeking or accepting this type of care (Clark-Tasker, 2002). Clark-Tasker (2002) conducted a study that included two focus groups of black men whose ages ranged from 38-80 years. The participants were asked to complete questionnaires based on a culturally appropriate video on prostate cancer. Results indicated that, on average, the men believed in the efficacy of prostate cancer early detection methods. Men between the ages of 40 and 50 years of age expressed concern about possible changes in their sex lives if diagnosed with prostate cancer. They also considered the digital rectal examination (DRE), one of the methods of screening, to be embarrassing and uncomfortable despite having limited knowledge of the disease.

In addition, Woods et al. (2004) used questionnaires to identify critical elements affecting black men and their screening for prostate cancer. The DRE was seen as threatening to sexuality. The participants were willing to take the DRE, but they found this procedure to be degrading, invasive, and felt it was associated with homosexual inclinations. Considering that many black men have historically be susceptible to deceptions of the medical profession and the ideology that the biomedical community is a white institution, the additional feature of an invasive exam is enough to keep black men from being screened, increasing the chances for advanced stage diagnosis. Depending on the level of distrust of the medical community, submitting to a digital rectal exam is not a routine procedure for black men. It involves rationalizing a culture specific mind-set and acquiescing to a screening method that could potentially save their lives. In particular in the Clark-Tasker (2002) study, black men perceived prostate cancer as a threat to their manhood because of the fear of impotence. The ability to perform sexually is regarded as a vital natural function of healthy men of all ages and is related to physical, emotional, and psychological well-being. Public Health has not addressed these critical barriers that plague the psyche of black male culture. Lack of understanding the social networks, which create values and norms that hold the black community together, are vital to successful interventions. Based on this perspective, health outcome is affected by the extent to which social integration allows appropriate health behavior norms to be created and supported. The prostate cancer screening disparity amongst black men is a result of a lack of social integration.

Today, there remains a great need for intervention strategies, including culturally competent approaches to prostate cancer for which there is effective treatment and prevention. Understanding health from a social perspective is important if appropriate interventions and policies are to be developed to engage black men in prostate cancer screening. Socioeconomic status, demographics, education, and access to care have been the criteria used to understand the factors that deter black men from being screened. This paper argues that these disparities are not the primary reasons for black detachment from the health care system. It is imperative to understand the black cultural and historical perspective in order to properly understand the elements contributing to late stage diagnosis of prostate cancer. The Tuskegee Syphilis Study continues to “cast its shadow” over the lives of black people. It has come to represent the inherent racism that permeates the American medical profession. While racism provides valuable insight, it cannot be the only prism used to examine the relationship between black people and the medical and public health communities

Black men’s lack of engagement with the health care system in general and more specifically prostate cancer screening occurs within a larger social context. This level of disconnectedness of black men from general society and the medical profession has persisted for a long time. To effectively reach black men, acknowledgement of previous negative experiences with healthcare, and proficient personal quality orientated delivery of care is necessary. Fostering a relationship between provider and patient while somewhat time consuming, is a culturally sensitive approach that will earn the trust of black men and allow for positive shared decision-making. Consideration of black men who have a history of lack of respect shows the providers commitment to care and to treat. This will assist in gradually breaking down the armor of distrust that keeps black men from seeking medical care, particularly with regards to prostate cancer screening.


Woods, Diane et al. “Culture, Black Men, and Prostate Cancer: What Is Reality?” Cancer Control Nov-Dec. 2004: 388-395.

Gamble, Vanessa. “Under the Shadow of Tuskegee: African Americans and Health Care.” American Journal of Public Health Nov. 1997: 1773-1778.

Plowden, Keith et al. “Sociological Persepctives of Black American Health Disparity: Implications for Social Policy.” Policy, Politics, & Nursing Practice Nov. 2002: 325-332.

Ashford, Alfred et al. “Prostate Carcinoma Knowledge, Attitudes, and Screening Behavior among African American Men in Central Harlem, New York City.” The American Cancer Society Jan. 2001: 164-172.

Bhopal, Raj. “Spectre of Racism in Health and Health Care: Lessons From History and the United States.” British Medical Journal June. 1998: 1970-1973.

Chan, Evelyn C. et al. “Informed Consent for Cancer Screening With Prostate-Specific Anitgen: How Well Are Men Getting the Message?” American Journal of Public Health
May. 2003: 779-785.

Cowart, Luvenia. “Educating African American Men About Prostate Cancer: The Barbershop Program.” American Journal of Health Studies Sept. 2004: 1-12.

Clarke-Tasker, Veronica A. “What We Thought We Knew: African American Males’ Persceptions of Prostate Cancer and Screening Methods.” ABNF Jounral May-June. 2002: 1-10.

Corbie-Smith, Giselle. “Attitudes and Beliefs of African Amerians Towards Participation in Medical Resarch.” Journal of General Medicine Sept. 1999: 537-546.

Hoffman, Richard et al. “Racial and Ethnic Differences in Advanced-Stage Prostate Cancer: the Prostate Cancer Outcomes Study.” Journal of the National Cancer Institute March. 2001: 388-395.


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