Indigenous men in Alberta get fewer prostate cancer tests, have more aggressive disease at diagnosis, and are more likely to have their cancer spread than non-Indigenous men, according to a new study by a University of Alberta research team.
Their paper outlining disparities in prostate cancer screening, diagnoses, management and outcomes between Indigenous and non-Indigenous men within a publicly funded health-care system was published today in the journal Cancer.
“We found that Indigenous men were more likely to be diagnosed with a more aggressive and higher-stage cancer compared to non-Indigenous men, and that the PSA (screening test level) at which they were diagnosed was higher than in non-Indigenous men,” explains principal investigator Adam Kinnaird, assistant professor in the Faculty of Medicine & Dentistry.
“When we looked at outcomes, we found that Indigenous men were more likely to develop prostate cancer metastases than non-Indigenous men,” adds Kinnaird, who is the Frank and Carla Sojonky Chair in Prostate Cancer Research and chair of the Alberta Prostate Cancer Research Initiative.
The research team says more work is needed to determine the underlying causes of the disparities, but many Indigenous people report a lack of equitable access to health-care services, says co-author Wayne Clark, executive director of the U of A’s Wâpanachakos Indigenous Health Program.
“I wasn’t surprised by the results, because they reflect what we know anecdotally about the experience of Indigenous people within the health-care system,” says Clark, who is Inuk registered under the Nunavut Agreement. “We need to consider traditional practices, focus on resiliency and shift away from deficit models when we’re looking for solutions.”
Disparities exist despite universal health care
The study was inspired by extensive research on disparities Black men experience in the United States, where the disparities in screening and outcomes are attributed to lower socioeconomic status and less access to health-care resources.
“What's interesting is that when you look at Black Canadians or Black British men with access to universal health care, you see that those differences in prostate cancer outcomes are significantly lessened or completely eliminated,” Kinnaird says.
“It is very interesting that, despite there being a universal health-care system here, we are seeing marked discrepancies in prostate cancer diagnoses and outcomes for Indigenous men,” Kinnaird says. “It really raises the question as to whether our public health-care system is adequately serving Indigenous Albertans, or whether there is another explanation that we just have not yet explored.”
The research team included a number of Indigenous members, such as Elder-in-residence Patrick Lightning, Randy Littlechild, who is executive director of Maskwacis Health Services, and Angeline Letendre with Alberta Health Services. Three frequently reported barriers to health-care access experienced by Indigenous people in Canada are substandard quality of care, long wait times, and experiences of racism and discrimination, the researchers report in their paper.
Early detection is key
The prostate is a small gland that produces seminal fluid. Prostate cancer is the third most common cause of death in Canadian men. One in eight men in Canada will develop prostate cancer and one in 29 will die from it, according to the Canadian Cancer Society. Screening for prostate cancer is done with a laboratory test to measure levels of prostate-specific antigen (PSA) in the blood, a protein that is often higher in men with cancer. Guidelines from the Canadian Urological Association recommend the screening be done every one to four years for men between ages 50 and 70, depending on their risk levels and results. Kinnaird points out that early diagnosis is key to recovery.
“Men who are diagnosed with localized cancer that stays in the prostate and receive surgery or radiation have a 10-year life expectancy that is greater than 95 per cent,” he says. “If you are diagnosed with metastatic prostate cancer, it is no longer considered curable. We give life-prolonging therapies, but the median five-year survival rate is only approximately 30 per cent.”
The researchers examined Alberta health records for more than 1.4 million men between June 2014 and October 2022. People living in First Nations communities and Métis settlements were identified by postal code, since Alberta does not track racial or ethnic background on personal health records. They found that in Indigenous communities, 32 men out of 100 received the screening test within a one-year time period, compared with 46 out of 100 men in non-Indigenous communities.
Among the more than 6,000 men who were diagnosed with prostate cancer, the researchers found that Indigenous men had higher PSA levels and more advanced disease. They were also at higher risk of developing metastatic cancer than the non-Indigenous men. There was no difference in mortality, likely because the followup period was only 40 months.
Seeking causes, solutions in partnership with community
The study was funded by the University Hospital Foundation, the Alberta Cancer Foundation, the Bird Dogs and several private donors. Adam Kinnaird is a member of the Cancer Research Institute of Northern Alberta.
Kinnaird and his team have a number of followup studies planned to try and determine the reasons behind the disparities they found. They will continue to follow the men who were diagnosed with cancer for a longer time period to determine their overall and cancer-specific mortality rates. They will work with Alberta’s Tomorrow Project, which has been collecting data about cancer in Alberta since 2000, to learn whether Indigenous men living in urban communities have different experiences than those in rural settings. And they will search for genetic differences that may make Indigenous men more susceptible to prostate cancer.
“We know that in Ashkenazi Jewish men, as well as in men of Caribbean descent, the rates of mutations for things like BRCA1 and BRCA2 are much higher than than in other men, and these are mutations that predispose to higher rates of prostate cancer, more aggressive prostate cancers and worse outcomes from prostate cancer,” says Kinnaird. “It is possible that Indigenous men also harbour some mutations that have not yet been recognized.
“We are teaming up with Indigenous collaborators and Indigenous elders to make sure that we do the following studies in keeping with the cultural norms, wants and beliefs of Indigenous men,” Kinnaird notes.
They will also explore community-based solutions to improve access to prostate cancer screening for men living in Indigenous communities. One plan is to send the “Man Van” to northern Alberta communities. The mobile screening clinic checks for prostate cancer as well as diabetes and mental health issues.
Wayne Clark believes such innovative solutions will result from bringing academic and community resources together, creating a collaborative model that could be applied across the country.
“We need to have a dialogue with Cree men about this to take away the stigma,” he says. “When Indigenous people are involved in program design for community-based interventions, they’re more likely to work.”