Prostate Cancer Screening Guidelines for Black Men: Spotlight on an Empty Stage

A 2-fold or more increased risk of prostate cancer death among Black men in the United States has been on record since the National Cancer Institute began its Surveillance, Epidemiology, and End Result program (1). In 2008-2012, just before the US Preventive Services Task Force (USPSTF) recommended against routine prostate-specific antigen (PSA) screening for prostate cancer, the age-adjusted mortality among Black men was 2.4 times that among White men, exceeding Black men’s 1.7-fold increased incidence (2). It is now well understood that societal factors and lack of access to quality care explain a large portion of the excess mortality among Black men (3) and that translational health services solutions are needed to narrow the gap and improve prostate cancer outcomes in this high-risk population.

The 2012 USPSTF guideline explicitly stated that its D recommendation applied to men in the general US population. Whereas the panel recognized the elevated risk of prostate cancer mortality among Black men, it did not provide any guidance for them, noting that “Black men represented a small minority of participants in the randomized clinical trials of screening” and concluding that “it is problematic to selectively recommend PSA-based screening for Black men in the absence of data that support a more favorable balance of risks and benefit” (4).

Several studies have shown that prostate cancer screening declined after 2012 following the USPSTF’s D recommendation (5,6). In this issue of the Journal, Kensler et al. (7) break down this decline and the accompanying trends in disease incidence by race and show that Black men had a modestly more pronounced drop in PSA screening than non-Hispanic White men. This is cause for concern. It echoes the worries of many patients, researchers, and advocates who feared that the guidelines could exacerbate prostate cancer mortality among Black men (8).

In 2018, the USPSTF softened its recommendation, giving prostate screening a grade C (9) and recommending shared decision-making for men aged 55-69 years. The new recommendation acknowledged updated evidence from 2 large screening trials (10,11) which had informed the prior guideline. However, the new recommendation again did not provide explicit guidance for Black men. It simply stated that men should “consider the balance of benefits and harms on the basis of family history, race/ethnicity, and other health needs.”

In this editorial, we make the case that the disproportionate burden of prostate cancer in Black men warrants tailored national guidelines and that enough information is available to inform targeted screening recommendations for this population. We posit that had a screening guideline been in place for Black men, we would not have observed the decreases in screening recorded in this population or the associated increases in adverse disease at diagnosis noted by Kensler et al. (7)

Black men have largely been underrepresented in randomized control trials of prostate cancer screening and treatment (12,13). When results from PSA screening trials with long-term follow-up suggested that screening was beneficial, there were too few Black men for any meaningful subanalysis to inform policy. However, clinical studies have now convincingly shown little or no disparity in disease-specific survival by stage when all men receive similar care (3,14,15). A trial where screening and biopsy referral are standardized would create the same opportunity for early detection in Black men as in the rest of the trial participants.

The dramatic effect of screening on disease stage has been documented in the European Randomised Study of Screening for Prostate Cancer trial (16) and in the US population, where advanced-stage incidence plummeted in the decade after the widespread adoption of PSA screening (17). It is noteworthy that the relative drop in advanced disease during this time was similar among Black and White men (17). This suggests that had Black men been adequately represented in the trial, they would likely have experienced a clinically significant drop in advanced disease of the order of that observed in the trial as a whole (16). Although screening cannot address differences in survival that are due to disparities in care postdiagnosis, its effect on disease stage makes it an important and potentially potent tool for disease control in Black men. But developing a well-founded approach for targeted screening in Black men requires understanding how their disease differs from the average-risk population (18).

In an analysis (17) of race-specific patterns of prostate cancer before and after the introduction of PSA screening, we inferred that Black men had a markedly increased risk of latent disease onset compared with the general population. This implies that the cumulative risk of developing potentially fatal prostate cancer among Black men at a given age (eg, 40 or 45 years) parallels that in the general population up to 10 years older (ie, 50 or 55 years). In the interest of providing an equitable opportunity for benefit, therefore, Black men should be considered eligible for screening 10 years before the rest of the general population. If the USPSTF gives prostate cancer screening a grade C for men aged 55-69 years, we would advocate for the same recommendation for Black men beginning at age 45 years.

And what of the balance of benefit to harm that is so critical for policy decisions? In a population with a higher risk of disease onset, there is also a higher potential for overdiagnosis in the presence of screening (18). Fortunately, initiating screening at younger ages is unlikely to impact overdiagnosis. However, the increased risk of disease onset at all ages argues for conservative screening and biopsy among older Black men who have a high risk of overdiagnosis and overtreatment. It further implies that active surveillance, which has been shown to be similarly safe for Black and White men with low-risk, localized prostate cancer (19-23), should be considered a primary management option for older Black patients with low-risk disease.

At a time of acute awareness of health inequity and in a new era of precision cancer control, the issuance of prostate cancer screening guidelines tailored to Black men must rank as a high priority for an easily implementable policy solution. Kensler et al.’s analysis (7) is telling us that it is high time for national prostate cancer early detection panels to step up and meet this moment.

Funding

These investigators are supported by the National Cancer Institute at the National Institutes of Health (award numbers U01CA199338, RE), the Department of Defense CDMRP (W81XWH1910577, YAN), and the Andy Hill Cancer Research Endowment (CARE) Fund (YAN). Etzioni’s work is supported in part by the Rosalie and Harold Rea Brown Endowment.

Notes

Role of the funders: The funders had no role in the writing of the editorial or decision to submit it for publication.

Disclosures: The authors have no conflicts of interest to disclose.

Author contributions: Ruth Etzioni, Writing - original draft; Yaw Nyame, Writing - review & editing.

Data Availability

Not applicable.