The intersection of race and adiposity in prostate cancer: a narrative review

Prostate cancer (PCa) is among the most common malignancies worldwide, with Black men experiencing significantly higher incidence, earlier onset, and more aggressive disease. These disparities reflect a complex interplay of factors. Adiposity, particularly visceral and periprostatic adipose tissue (PPAT), has emerged as a potential contributor to PCa progression, though its role in modifying racial disparities remains unclear. We conducted a narrative review to evaluate the relationship between obesity, visceral adiposity, PPAT, and PCa risk and aggressiveness, with attention to racial differences. A directed acyclic graph was developed to illustrate hypothesized pathways. Strong evidence supports associations between obesity, visceral fat, and aggressive PCa. Black men tend to have lower visceral and PPAT volumes than White men. However, these depots may exert greater biological effects in Black men, possibly due to differences in inflammatory signaling or fat composition. PPAT and waist-hip ratio may amplify aggressive PCa features in Black men while downplaying them in non-Black men. Adiposity may serve as a biomarker and modifier of racial disparities in PCa. An improved study design is needed to clarify mechanisms and inform targeted interventions. Understanding these interactions is essential to reducing PCa disparities in high-risk populations.