Why Prostate Cancer Screening Guidelines Should Be Race-Specific

A common belief many men have of prostate cancer is that it's not aggressive, and they're more likely to die from other causes. While this may be true to some extent for most men, it doesn't necessarily apply to those of African American descent.

US Black men have the highest incidence of prostate cancer in the world. In the US, they are about 70 percent more likely to be diagnosed and more than twice as likely to die from prostate cancer than other men. In addition, studies have also found differences between Black and White men in the clinical course of the disease, serum PSA levels, tumor characteristics, and socio-economic issues that result in poorer treatment outcomes for Black men.

However, despite being a high-risk population, The US Preventive Services Task Force's screening recommendations don't provide clear guidance to Black men. The USPSTF currently advises that all men between the ages of 55 and 69 talk to their doctors about their family and personal medical histories and develop a screening plan based on evaluations of their individual risk factors.

Critics say this recommendation fails to emphasize to health insurers and healthcare providers the heavier disease burden Black men face. They also point out that beginning screening discussions with their doctors at 55 may be too late for many Black men who are more likely to get prostate cancer at a younger age, tend to have more aggressive disease and be diagnosed at more advanced stages. That's why other organizations provide more race-specific information. The American Cancer Society, for example, includes African American men in its high-risk category of men who should start discussing screening with their doctors at age 45. ACS recommends even earlier discussions beginning at age 40 for men with more than one first relative who had prostate cancer at an early age. The Prostate Cancer Foundation also advises early screening discussions beginning at age 45 for Black men. However, it's even more specific about starting screening discussions at age 40 if a man has a family history of prostate, breast, ovarian, pancreas, or other cancers, is Black, or has known BRCA 1 or 2 mutations.

Screening for prostate cancer is somewhat controversial, and recommendations have changed over the years. Studies show that screening men between 45 and  70 using a blood test called a prostate-specific antigen or PSA test reduces the likelihood of dying by just under one-third. Early detection also increases the chances of curing the disease if treatment is warranted. 99% of men diagnosed with early-stage, local, or regional prostate cancer live five years after diagnosis. Among men diagnosed with advanced disease, the five-year survival rate falls to 32%. Early detection also allows for doctors to monitor or conduct "active surveillance of slow-growing prostate tumors instead of immediate treatment.

So why isn't more wide-scale PSA screening recommended? It's a matter of balancing the benefits with the risks of overdiagnosis and treatment. Because many men might not have symptoms or see their prostate cancer manifest over their lifetimes, finding it may not improve their health or help them live longer. False positives can also occur, leading to follow-up biopsies, resulting in side effects like rectal bleeding, blood in the semen and urine, difficulty urinating, infections, and periods of sexual dysfunction. So researchers are studying ways to maximize the benefits of screening while minimizing the risks.

Dr. Yaw Nyame, a urological oncologist at the University of Washington School of Medicine, conducted a model-basis analysis study on the impact of intensifying prostate cancer screening among Black men. He found that screening Black men between 40 and 84 would decrease mortality by about 30%. Still, it would also result in about 112-129 cases of overdiagnosis per every 1000 men, or roughly 10%. When Nyame narrowed the age window to between 45 and 69, he found similar levels of benefit. It reduced mortality by 26 to 29% but resulted in only about half as many cases of overdiagnosis, 51 to 61 per 1000 men per year. So in an article published in the Journal of the National Cancer Institute, Nyame concluded that intensifying screening of Black men between 45 and 69 makes the most sense in balancing the benefits and risks. Nyame added that following up on abnormal tests with biopsies would further reduce prostate cancer mortality among Black men, but it would substantially increase overdiagnosis too.

Another study published this month in JAMA Network Open analyzed race and treatment outcomes of men with advanced prostate cancer. It found no statistical difference in overall survival between Black and White patients. The authors say providing fair and equitable access to care for prostate cancer may reduce historical differences in outcomes between Black and White patients.

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