Rising metastatic prostate cancer rates but narrowing racial gap

Abstract

Background

In recent years, there has been considerable interest in addressing racial disparities in prostate cancer (PCa) care including risk-adapted screening. This study examined trends in metastatic PCa incidence by race and placed them in context of changes in PSA screening recommendations.

Methods

We analyzed metastatic PCa incidence trends by race (using Surveillance Epidemiology and End Results data, 2005–2021) and PSA screening trends (using Behavioral Risk Factors Surveillance Survey data, 2012–2020). We fitted a generalized linear model with an interaction term for race and year of diagnosis and calculated annual incidence rate ratios (metastatic disease) and odds ratios (screening) for Non-Hispanic Black (NHB) vs. Non-Hispanic White (NHW) men.

Results

From 2005 to 2021, the age-adjusted metastatic PCa incidence (per 100,000) increased from 16.4 to 22.3 in NHB men, and from 6.2 to 10.8 in NHW men. While the incidence increased in both groups, the NHB vs. NHW incidence rate ratio declined from 2.6 (95%CI: 2.4, 2.9) in 2005 to 2.1 (95%CI:2.0,2.2) in 2021 (p < .0001), indicating a narrowing racial gap. From 2012 to 2020, PSA screening declined in both groups. NHB men initially had higher rates (OR:1.34, 95%CI: 1.21, 1.49, p < 0.0001) but experienced a steeper decline, resulting in no significant difference by 2020 (OR: 1.04, 95% CI: 0.91, 1.19, p = 0.59).

Conclusions

The racial gap in metastatic PCa narrowed over the study period, while overall incidence increased. Higher screening rates among Black men in the early 2010s may explain the narrowing gap. The subsequent more rapid decline among Black men raises concerns about resurgence of racial disparities in the coming years.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12916-025-04448-6.

Background

Black men are twice as likely to die from prostate cancer (PCa) compared to White men [1]. Although rates of more aggressive PCa subtypes appear to be higher among Black men [2, 3], a growing body of literature highlights the significant role of access to care and socioeconomic factors as major contributors to disparities in PCa outcomes [4, 5]. Numerous studies investigating PCa outcomes in settings with equal access to care have demonstrated attenuation in outcomes between Black and White men [6–8]. Over the past two decades, there has been substantial research and health policy investment in identifying and addressing racial disparities in PCa care. Meanwhile, PCa screening guidelines have evolved, including the incorporation of Black race as a trigger for earlier screening in 1997 [9], and the USA Preventive Services Task Force general recommendation against screening for all patients in 2012. Subsequently, an increasing incidence of metastatic PCa was reported [10–12]. Revised recommendations in 2018 advocate shared decision-making. Notably, this incorporates individual risk factors including race/ethnicity [13].

Although some efforts to study changing metastatic disease incidence following the screening guideline changes have been published, the long-term effects on the incidence of metastatic PCa in different racial and ethnic groups remain understudied.

In this setting, we investigated whether trends in the incidence of metastatic PCa from 2005 to 2021 differed by race/ethnicity. Furthermore, we sought to assess whether any observed changes in the incidence of metastatic disease coincided with race-based changes in the rate of prostate-specific antigen (PSA) screening. We hypothesized that there would be rising rates of metastatic disease and declining odds of screening across our study period and that the trends would differ based on patient race/ethnicity.

Methods

Study design

We used data from the Surveillance, Epidemiology, and End Results (SEER) database (Research Limited Field Data, 22 Registries) [14] from 2005 to 2021 to study trends in metastatic PCa incidence rates by race/ethnicity. Additionally, we analyzed Behavioral Risk Factor Surveillance System (BRFSS) survey data [15] from 2012 to 2020 to examine national PSA screening trends by race/ethnicity. These were the earliest years for which consistent recent screening data is available. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies [16]. This study used only de-identified data and was approved and exempted from review by the Brigham and Women’s Institutional Review Board.

Metastatic prostate cancer incidence rates (SEER data)

SEER is a population-based cancer registry maintained by the National Cancer Institute in the USA. The SEER Research Limited-Field Data provides cancer incidence rates and covers about 47.9% of the US population [17]. We queried the SEER database (Research Limited Field Data, 22 Registries, Nov 2022 Sub (2000–2020)) for annual age-adjusted incidence rates of metastatic PCa in non-Hispanic Black (NHB) and non-Hispanic White (NHW) men between 2005 and 2021. The study cohort was limited to NHB and NHW men of any age diagnosed with metastatic PCa. The SEER Combined Summary Stage was used to identify patients diagnosed with metastatic PCa at initial presentation. This was done to focus on advanced disease which could plausibly be related to lack of screening rather than disease which progresses after diagnosis and treatment. Age-adjusted incidence rates (per 100,000 individuals) of metastatic PCa were extracted from the SEER database using the SEER*Stat 8.3.4 software.

Statistical analysis (SEER data)

The SEER data are not at the patient-level, but instead are at the national level. In particular, the SEER data are in the form of annual age-adjusted estimated incidence rates of metastatic PCa for NHW and NHB men from 2005 to 2021, excluding men of other or unknown races and ethnicities. Patients who were initially diagnosed with localized PCa and subsequently developed distant metastases were not included in our analysis. A log-linear regression model was then fit to 34 national age-adjusted incidence rates, with main effects for race and categorical calendar year, and their interaction. With year as a categorical covariate, this model is completely non-parametric in that we are not assuming any trend in time for NHW or NHB. The parameters of the log-linear regression model were calculated using optimal weighted least squares [18] (weighted by the inverse of the estimated variance for each rate) with a log-link. This model allows us to test if the annual incidence rate ratio changes over time by testing if the interaction in the model is significant. The exponential of linear combinations of the main effects and interaction terms from the log-linear regression model are used to estimate annual rate ratios of NHB versus NHW men (these are often called ‘marginal effects’).

PSA screening rates (BRFSS data)

BRFSS is an annual, nationwide telephone-based survey conducted by the US Center for Disease Control and Prevention. It collects data from adult US residents on health-related risk behaviors, chronic health conditions and the use of preventive services. With over 400,000 interviews conducted annually across all 50 states, it is the largest continuous health survey in the world. We analyzed individual-level BRFSS survey data from 2012, 2014, 2016, 2018 and 2020, as the PSA screening question was included only in biennial surveys. We excluded survey data before 2012 because a different statistical weighting method was used in earlier years. Data from 2022 was also excluded because the PSA screening question was only asked in a limited number of states. Our BRFSS study cohort included NHW and NHB men aged 40–69 years, selected based on current AUA guidelines [19]. The AUA recommends offering PSA screening to Black men beginning at age 40–45 and to the general population between 50 and 69. Men with a prior diagnosis of PCa were excluded from the analysis. The primary outcome was receiving a PSA screening within 2 years prior to the survey, identified using the BRFSS variable ‘psatime’. The primary explanatory variables of interest were self-reported race (NHB, NHW) and survey year (2012, 2014, 2016, 2018 and 2020). Additional covariates included were health insurance, self-reported health status, highest level of education, marital status and median household income (MHI).

Statistical analysis (BRFSS data)

We calculated descriptive summary statistics for the study cohort at two levels: the individual survey participant level and the population level. Population-level estimates were derived using survey weights, which accounted for the complex sampling design. We calculated the weighted proportions of NHW and NHB men who received PSA screening within 2 years for each survey year. A multivariable logistic regression analysis of predictors of PSA screening from 2012 to 2020 was conducted. The primary explanatory variables of interest included in the model were race/ethnicity and survey year. The variable survey year was specified as a categorical variable, with 2012 as the reference year, so each year’s odds ratio represents the change in screening odds compared to 2012. The model was adjusted for health insurance, self-reported health status, highest level of education, marital status and MHI.

Both primary explanatory variables of interest were significant predictors of PSA screening. A second multivariable logistic regression analysis was performed incorporating an interaction term between race and survey year. A subgroup analysis was conducted to calculate the odds ratio (OR) for PSA screening between NHW and NHB men for each survey year separately. This analysis adjusted for health insurance, health status, highest level of education, marital status and MHI.

Statistical analysis of SEER and BRFSS data were conducted using the Stata 17.0 BE-Basic Edition (Stata Corp, College Station, TX). Two-sided significance tests were applied, with p values less than 0.05 considered statistically significant.

Results

Metastatic prostate cancer incidence rates 2005–2021

The age-adjusted incidence rate of metastatic PCa per 100,000 men increased in both racial/ethnic groups from 2005 to 2021 (Fig. 1A). Among NHB men, the incidence rate increased from 16.4 (95% CI: 15.2, 17.7) to 22.3 (95% CI: 21.2, 23.4), while in NHW men it increased from 6.2 (95% CI: 6.0, 6.5) to 10.8 (95% CI: 10.5, 11.1). Table 1 shows the annual age-adjusted incidence rates of metastatic PCa in NHB and NHW men, along with the incidence rate ratios for each year. The annual incidence rate of metastatic PCa decreased between 2005 and 2010 but then increased from 2010 to 2021 in both racial groups. Despite the overall increase in metastatic PCa incidence from 2005 to 2021, the increase was slower among NHB men compared to NHW men over the study period (Fig. 1A). The incidence rate ratio (NHB vs. NHW) declined from 2.6 (95% CI: 2.4, 2.9) in 2005 to 2.1 (95% CI: 2.0, 2.2) in 2021 (p < 0.0001), indicating a narrowing of the racial gap in metastatic PCa incidence (Table 1, Fig. 1B). Table S1 (Additional file 1) additionally shows, for each year from 2005 to 2021, the SEER population (total number of NHW and NHB males of all ages within the SEER registry area) and the count (number of men in each group with newly diagnosed metastatic prostate cancer).

Fig. 1.

Trends in metastatic prostate cancer incidence and PSA screening rates by race/ethnicity

Table 1.

Annual incidence rates of metastatic prostate cancer of NHB and NHW men and annual incidence rate ratios of NHB to NHW men (SEER Data)

Year	Rate NHB*	Rate NHW*	Incidence Rate Ratio (IRR)	Lower CI (IRR)	Upper CI (IRR)	p value (IRR = 1 for each year)
2005	16.4	6.2	2.6	2.4	2.9	<.0001
2006	15.7	6.5	2.4	2.2	2.6	<.0001
2007	15.4	6.2	2.5	2.3	2.7	<.0001
2008	14.8	6.1	2.4	2.2	2.6	<.0001
2009	15.6	6.1	2.6	2.4	2.8	<.0001
2010	14.7	6.2	2.4	2.2	2.6	<.0001
2011	15.1	6.3	2.4	2.2	2.6	<.0001
2012	15.1	6.8	2.2	2.1	2.4	<.0001
2013	16.1	7.1	2.3	2.1	2.5	<.0001
2014	16.4	7.6	2.2	2.0	2.3	<.0001
2015	16.7	8.5	2.0	1.8	2.1	<.0001
2016	18.0	8.9	2.0	1.9	2.2	<.0001
2017	19.7	9.6	2.0	1.9	2.2	<.0001
2018	20.0	9.8	2.0	1.9	2.2	<.0001
2019	20.2	10.1	2.0	1.9	2.1	<.0001
2020	19.3	10.1	1.9	1.8	2.0	<.0001
2021	22.3	10.8	2.1	2.0	2.2	<.0001

All estimates pertain to the United States. The p values (IRR = 1 for each year) refer to tests for no differences in incidence rates between NHB and NHW men in each study year. The p-value for testing if IRRs were equal across all years was < 0.001 (interaction p value between year and race in log-linear model for rates), indicating significant changes in IRRs over time

NHB non-Hispanic Black, NHW non-Hispanic White, IRR incidence rate ratio

^*Metastatic Prostate Cancer Incidence Rate per 100,000 men. Datasource: SEER (Research Limited Field Data, 22 Registries, 2005–2021)

PSA screening rates 2012–2020

A total of 362,357 men from the BRFSS survey years 2012–2020 met the inclusion criteria and were included in the analysis, representing an estimated weighted population of 36 million men nationwide. Of the weighted study population, 85.9% were NHW and 14.1% were NHB. Additionally, 51.0% were aged 40–54 years, while 49.0% were aged 55–69 years. Overall, 36.7% of the weighted study population received PSA screening within the past 2 years. The remaining baseline characteristics, both at the survey participant level and as weighted population estimates, are presented in Table 2. The proportion of NHW men who received PSA screening within the past 2 years decreased over the study period. The proportion was 43% in 2012, 40% in 2014, 38% in 2016, 30% in 2018 and 29% in 2020. The proportion of NHB men who received PSA screening also decreased, with 44% in 2012, 43% in 2014, 37% in 2016, 29% in 2018, and 26% in 2020 (Fig. 1C). In the multivariate logistic regression analysis of predictors of PSA screening, both primary explanatory variables, race/ethnicity and survey year, were significant predictors. NHB men had significantly higher odds of receiving PSA screening compared to NHW men (OR 1.25, 95% CI 1.19, 1.31, p < 0.0001). Compared to 2012, the odds of screening were lower in all subsequent years, with a steady decline in ORs from 2014 to 2020. In 2014, the OR was 0.85 (95% CI 0.82, 0.88, p < 0.0001), and by 2020, it had decreased to 0.48 (95% CI 0.46, 0.50, p < 0.0001). The remaining results of the regression model are presented in Table 3. A second multivariable regression model, which included an interaction term between race and survey year, revealed a significant interaction between these two predictors (p = 0.0008). The subgroup analysis of predictors of screening for each BRFSS year separately showed that NHB men had significantly higher odds of PSA screening in the earlier study period. In 2012, 2014, and 2016, NHB men had consistently higher odds compared to NHW men. However, a more rapid decline in screening among NHB men was observed over time, resulting in steadily decreasing odds ratios (Table 4). By 2020, the difference in screening between NHB and NHW men was no longer statistically significant (OR 1.04, 95% CI 0.91–1.19, p = 0.587) (Fig. 1D).

Table 2.

Baseline characteristics of non-Hispanic Black and non-Hispanic White men aged 40–69 in the Behavioral Risk Factor Surveillance system (BRFSS) database from 2012 to 2020

		Survey participants n (%)	Estimated population in millions n (%)	Estimated population in millions 95%CI
Total		362,357 (100%)	36 (100%)	36 to 36
Age	40–54	144,825 (40.0%)	18 (51.0%)	18 to 18
	55–69	217,532 (60.0%)	18 (49.0%)	17 to 18
Health insurance	No	28,773 (7.9%)	3.4 (9.5%)	3.3 to 3.5
	Yes	333,584 (92.1%)	32 (90.5%)	32 to 33
Health status	Excellent	63,640 (17.6%)	6.3 (17.5%)	6.2 to 6.4
	Very good	127,342 (35.1%)	12 (34.1%)	12 to 12
	Good	110,605 (30.5%)	11 (30.9%)	12 to 12
	Fair	42,831 (11.8%)	4.4 (12.3%)	4.3 to 4.5
	Poor	17,939 (5.0%)	1.8 (5.1%)	1.8 to 1.9
Highest level of education	Less than high school	17,977 (5.0%)	3.2 (8.9%)	3.1 to 3.3
	High school	99,312 (27.4%)	11 (29.3%)	10 to 11
	Attended College	94,960 (26.2%)	11 (30.5%)	11 to 11
	Graduated	150,108 (41.4%)	11 (31.3%)	11 to 11
Marital Status	Alone	117,899 (32.5%)	11 (31.4%)	11 to 11
	Married/Couple	244,458 (67.5%)	25 (68.6%)	24 to 25
Race/Ethnicity	NHW	333,034 (91.9%)	31 (85.9%)	31 to 31
	NHB	29,323 (8.1%)	5.1 (14.1%)	5.0 to 5.2
PSA screening in the past 2 years	No	216,312 (59.7%)	23 (63.3%)	23 to 23
	Yes	146,045 (40.3%)	13 (36.7%)	13 to 13
MHI	< $25,000	65,478 (18.1%)	6.6 (18.5%)	6.5 to 6.7
	$25,000-$35,000	28,365 (7.8%)	2.7 (7.4%)	2.6 to 2.7
	$35,000-$50,000	46,605 (12.9%)	4.4 (12.2%)	4.3 to 4.4
	$50,000 or 75,000	62,592 (17.3%)	6.0 (16.6%)	5.9 to 6.0
	> 75,000	159,317 (44.0%)	16 (45.3%)	16 to 16
BRFSS year	2012	78,252 (21.6%)	7.9 (22.1%)	7.9 to 8.0
	2014	76,915 (21.2%)	7.6 (21.2%)	7.5 to 7.7
	2016	78,022 (21.5%)	7.7 (21.3%)	7.6 to 7.7
	2018	69,609 (19.2%)	6.9 (19.1%)	6.8 to 7.0
	2020	59,559 (16.4%)	5.8 (16.3%)	5.8 to 5.9

Datasource: Behavioral Risk Factor Surveillance System Database (2012–2020). All estimates pertain to the United States

NHB non-Hispanic Black, NHW non-Hispanic White, PSA prostate-specific antigen, MHI median household income, BRFSS Behavioral Risk Factor Surveillance System

Table 3.

Multivariable logistic regression analysis of predictors of PSA screening among non-Hispanic Black and White men aged 40–69, 2012–2020 (BRFSS data)

		OR	95%CI	p value
Health insurance	No	–	–	–
	Yes	3.22	3.02 3.43	< 0.0001
Health status	Excellent	–	–	–
	Very good	1.10	1.06 1.14	< 0.0001
	Good	1.14	1.09 1.18	< 0.0001
	Fair	1.25	1.19 1.32	< 0.0001
	Poor	1.32	1.23 1.42	< 0.0001
Highest level of education	Less than high school	–	–	–
	High school	1.43	1.33 1.53	< 0.0001
	Attended College	1.74	1.62 1.87	< 0.0001
	Graduated	2.08	1.94 2.24	< 0.0001
Marital status	Alone	–	–	–
	Married/Couple	1.38	1.34 1.43	< 0.0001
Race/Ethnicity	NHW	–	–	–
	NHB	1.25	1.19 1.31	< 0.0001
MHI	< $25,000	–	–	–
	$25,000-$35,000	1.20	1.13 1.28	< 0.0001
	$35,000-$50,000	1.30	1.24 1.37	< 0.0001
	$50,000 or 75,000	1.28	1.22 1.35	< 0.0001
	> 75,000	1.27	1.21 1.33	< 0.0001
BRFSS year	2012	–	–	–
	2014	0.85	0.82 0.88	< 0.0001
	2016	0.73	0.71 0.76	< 0.0001
	2018	0.52	0.50 0.54	< 0.0001
	2020	0.48	0.46 0.50	< 0.0001

Datasource: Behavioral Risk Factor Surveillance System Database (2012–2020). All estimates pertain to the United States

NHB non-Hispanic Black, NHW non-Hispanic White, MHI median household income, BRFSS Behavioral Risk Factor Surveillance System

Table 4.

Subgroup analysis: adjusted odds ratios for PSA screening among NHB and NHW men aged 40–69 years by year. Adjusted for: income, insurance, health status, education level, marital status. (BRFSS data)

Year	OR	95% CI	P Value
2012
NHW	–	–	–
NHB	1.34	1.21 1.49	< 0.0001
2014
NHW	–	–	–
NHB	1.41	1.27 1.55	< 0.0001
2016
NHW	–	–	–
NHB	1.26	1.14 1.40	< 0.0001
2018
NHW	–	–	–
NHB	1.13	1.02 1.26	0.017
2020
NHW	–	–	–
NHB	1.04	0.91 1.19	0.587

Datasource: Behavioral Risk Factor Surveillance System Database (2012–2020). All estimates pertain to the United States

NHB non-Hispanic Black, NHW non-Hispanic White, BRFSS Behavioral Risk Factor Surveillance System

Discussion

In this study, we investigated race-based trends in the incidence of metastatic PCa from 2005 to 2021 as well as race-based changes in PSA screening. Although the racial gap in metastatic PCa is narrowing, this occurred against a background of an increasing incidence of metastatic disease in both racial groups. Meanwhile, the PSA screening rate decreased in both racial groups from 2012 to 2020. Initially, NHB men had significantly higher PSA screening rates than NHW men in the early 2010 s (potentially accounting for the narrowing racial gap in the later study period). In contrast, more recent years saw a declining proportion of men undergoing screening with more rapid declines in Black men such as screening rates were no longer significantly different between the two racial groups.

Following the introduction of PSA testing in the late 1980 s and the subsequent widespread adoption of PSA screening in the USA, metastatic PCa rates declined by half from 1988 to 2012 [20, 21]. Our findings indicate that the rate of metastatic PCa decreased in both racial/ethnic groups from 2005 to 2009, but increased from 2010 to 2021. The overall increase in metastatic PCa rates in both racial groups is alarming. Similar to our findings, a recent study investigating the incidence rate of metastatic PCa in relation to the USPSTF recommendations of 2008 and 2012 reported an overall increase in the incidence of metastatic PCa from 2004–2018 with an initial decrease between 2004 and 2009 [12]. Our findings emphasize the continued rise in metastatic disease until 2021. While these trends are likely to be driven by multiple factors, the temporal association with changes in screening recommendations, as well as the high velocity of the change in incidence, strengthen the role of health policy changes, particularly in screening recommendations, as a key factor.

Although an observational study such as this cannot determine causal relationships between race-based trends in screening and metastatic cancer rates, our results help to contextualize the overall trends in both metastatic disease and cancer screening. The incidence rate of metastatic PCa increased in NHB men from 16.4 in 2005 to 22.3 in 2021, while in NHW men, it increased from 6.2 in 2005 to 10.8 in 2021. The incidence rate ratio between NHB and NHW men was 2.6 in 2005, indicating that NHB men had a nearly threefold higher incidence of metastatic PCa compared to NHW men. However, due to the less pronounced increase in metastatic disease among NHB men compared to NHW men, the incidence rate ratio declined over the study period, reaching 2.1 in 2021. Our BRFSS analysis provides critical context for the observed, race-based change in incidence rates and rate ratios over the study period. The earliest screening data from 2012 and 2014 showed higher screening rates in Black men, which may explain the narrowing racial gap in metastatic disease rates observed in the SEER analysis over our study period. Interestingly, in the last three study periods (2016, 2018 and 2020), this trend appeared to reverse, with a more rapid decline in crude screening rates among Black men. Similarly, the adjusted odds ratio of screening among NHB and NHW men from 2012 to 2020 showed significantly higher odds of screening in NHB men in the earlier years, followed by a decline until 2018, with no significant difference in PSA screening between NHB and NHW men in 2020. This suggests that screening declines in the late 2010 s may have occurred unequally by race. Contrary to guidelines that emphasize shared decision-making incorporating patient race [19, 22, 23], Black men experienced greater declines in screening. While these race-based trends have not yet translated into any reversal in the racial trends in metastatic incidence rates, the recent more rapid declines in screening among Black men could foreshadow a widening racial gap in metastatic disease in years to come. Our findings align with a previous analyses of race-based screening rates in the past decade. Kensler et al. reported a decline in PSA screening rates among NHB and NHW men from 2012 to 2018, with a steeper decline in NHB men [24]. A recent analysis from our group examined contemporary trends in PSA screening by race during and after the COVID-19 pandemic [25]. This study, covering 2018 to 2022, showed an initial decline in screening rates for both Black and White patients, followed by a recovery in screening rates. However, the post-pandemic recovery of screening rates was significantly faster in White patients than Black patients. In our study, we found that the incidence of metastatic prostate cancer increased in both, NHW and NHB men, but the gap between these groups narrowed from 2005–2020, as reflected by a steady decrease in incidence rate ratio from 2.6 in 2005 to 1.9 in 2020. However, we observed a sharper increase in metastatic prostate cancer in Black men than in White men from 2020 to 2021, resulting in an increasing incidence rate ratio. We hypothesize that the sharper decline in screening rates from 2012 to 2020 in Black men may have contributed to the sharper increase in metastatic disease. Considering our findings on race-based trends in metastatic disease, the disparity in post-pandemic PSA screening recovery between Black and White [25] men is concerning.

Previous research underscores the importance of social determinants of health when investigating racial disparities in PCa outcomes. A meta-analysis of more than one million PCa patients demonstrated that, when accounting for social determinants of health, Black men with PCa exhibited similar or better survival outcomes compared with White men [4]. Our findings suggest a plausible link between race-based PCa screening patterns and trends in racial disparities in PCa outcomes. It is possible that risk-adapted screening that prioritizes PSA screening in high-risk groups like Black men in earlier years of our analysis may have attenuated the rise in metastatic disease in these groups relative to White men. However, recently ethical concerns have been raised regarding race-based differences in PCa screening recommendations [26]. Current major guidelines that incorporate race-based screening use inconsistent terms such as “Black ancestry”, “African descent”, “African ancestry”, which suggest race as a biologic variable. Treating race as a biologic category for specific screening recommendations carries the risk of obscuring the impact of socioeconomic factors, which are likely the main drivers of poor PCa outcomes [26]. Nonetheless, based on current available literature and consensus discussion in an expert panel, the Prostate Cancer Foundation published Screening Guidelines for Black Men in the USA in 2024. These guidelines recommend risk-adapted screening, starting screening earlier (40–45 years of age) and/or more frequently compared with non-Black men in the USA [27].

Racial disparities in PCa outcomes are not limited to the USA. In the UK, Black men are also twice as likely to die from PCa as White men [28]. As in the USA, evidence from the UK suggests that equal access to treatment eliminates disparities in prostate cancer-specific mortality among patients who undergo treatment [29]. However, analyses of PCa screening disparities between White and Black men in the UK show conflicting results, with some studies reporting higher screening rates in White men and others reporting higher screening rates in Black men [29]. Therefore, screening may not be the primary mediator of racial disparities in PCa outcomes in the UK. This highlights the multifactorial origin of disparities in PCa outcomes in both the UK and the USA.

Several limitations must be acknowledged when interpreting the results of this study. First, and most importantly, we used the SEER database to analyze race-based trends in metastatic PCa. The SEER summary stage represents the stage at diagnosis. If patients are initially diagnosed with nonmetastatic PCa and later develop metastatic disease, they will not be included in this analysis. Furthermore, when PSA screening rates are higher, more men may be diagnosed with nonmetastatic PCa and may subsequently progress to metastatic disease compared to periods of lower PSA testing intensity. It is important to emphasize that SEER data reported in this study reflect metastatic PCa incidence rates at diagnosis only, and therefore, the results do not represent true population-based metastatic cancer rates. Second, the PSA screening data used in this study was based on the national telephone-based BRFSS survey. Certain subpopulations who have less access to telephones or have limited English proficiency may be underrepresented in the survey. However, questionnaires are also available in Spanish and the survey methodology included iterative proportional fitting to weight BRFSS survey data. Third, our analyses included only NHB and NHW patients and did not include individuals from other racial or ethnic groups, who may also experience limited access to screening and worse PCa outcomes than White patients. Investigating screening patterns and outcomes in smaller minority groups is important to inform equitable healthcare strategies. However, we limited our analysis to NHB and NHW men because prior research indicates that NHB men represent a group that is especially disenfranchised and faces unique challenges in access to healthcare [30]. Lastly, we utilized self-reported PSA screening rates in our analysis. Previous studies investigating accuracy of self-reported cancer screening found that self-reported survey data might overestimate cancer screening utilization and indicate racial/ethnic differences in reporting accuracy [31]. However, despite its limitations, BRFSS survey data provide the largest continuously conducted health survey worldwide and offer valuable insights into national health-related risk behaviors and the use of preventive services.

Conclusions

Although the racial gap in metastatic PCa appears to be narrowing, this occurred against a background of increasing incidence of metastatic disease and declining screening rates in both racial groups. Higher screening rates among Black men in the early 2010 s may account for some of the narrowing of the gap in metastatic disease. However, the subsequent decline in screening across both racial groups, particularly among Black men, raises concerns about a potential increase in metastatic disease burden and a retrenchment of racial disparities in the coming years. Our findings underscore the importance of continued evaluation of the impact of past and current screening recommendations on race-based trends in metastatic PCa rates.

Authors’ contributions

HZ: conception of the work, data acquisition, data analysis, interpretation of the data, drafting of the manuscript, revision of the work. ZQ: conception of the work, data acquisition, revision of the work. KKP: conception of the work, revision of the work. AP: conception of the work, revision of the work. SMK: conception of the work, revision of the work. ML: supervision, revision of the work. SRL: data analysis, interpretation of the data. MC: data analysis, interpretation of the data. SAF: conception of the work, revision of the work. ML: supervision, revision of the work. SA: supervision, revision of the work. QDT: supervision, revision of the work. APC: conception of the work, interpretation of the data, supervision, revision of the work. All authors read and approved the final manuscript.

Funding

The authors declare no relevant financial or non-financial conflicts of interest related to this work.

Data availability

The datasets generated in this study are publicly available from the National Cancer Institute (Surveillance, Epidemiology, and End Results Program) and the US Centers for Disease Control and Prevention (Behavioral Risk Factor Surveillance System).

Declarations

Ethics approval and consent to participate

This study used only de-identified data and was approved and exempted from review by the Brigham and Women’s Institutional Review Board (Reference ID: 2021P001256).

Consent for publication

Not applicable.

Competing interests

Competing interests: Q-DT reports consulting fees from Astellas, Bayer, Intuitive Surgical, Janssen, Novartis, Pfizer, and research funding from the American Cancer Society, Pfizer Global Medical Grants (Prostate Cancer Disparities #63354905), and a Health Disparity Research Award from the Department of Defense Congressionally Directed Medical Research Program (#PC220551). APC reports research funding from the Bruce A Beal and Robert L Beal surgical fellowship of the BWH Department of Surgery, from the Prostate Cancer Foundation and American Cancer Society (#23YOUN25), and from a Physician Research Award from the Department of Defense Congressionally Directed Medical Research Program (#PC220342). He received proctoring fees from EDAP/Focal One. ML received honoraria from Astellas, ibsa, Ipsen and Novartis an research funding from Hollister. SMK reports speaker fees from Janssen, Astellas and research fund from the Max Kade foundation/Austrian Academy of Science. Funding: The authors declare no relevant financial or non-financial conflicts of interest related to this work.