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Kevin H Kensler, Roman Johnson, Faith Morley, Mohamed Albrair, Barbra A Dickerman, Roman Gulati, Sarah K Holt, Hari S Iyer, Adam S Kibel, Jenney R Lee, Mark A Preston, Jason L Vassy, Erika M Wolff, Yaw A Nyame, Ruth Etzioni, Timothy R Rebbeck, Prostate cancer screening in African American men: a review of the evidence, JNCI: Journal of the National Cancer Institute, Volume 116, Issue 1, January 2024, Pages 34–52, https://doi.org/10.1093/jnci/djad193
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Abstract
Prostate cancer is the most diagnosed cancer in African American men, yet prostate cancer screening regimens in this group are poorly guided by existing evidence, given underrepresentation of African American men in prostate cancer screening trials. It is critical to optimize prostate cancer screening and early detection in this high-risk group because underdiagnosis may lead to later-stage cancers at diagnosis and higher mortality while overdiagnosis may lead to unnecessary treatment.
We performed a review of the literature related to prostate cancer screening and early detection specific to African American men to summarize the existing evidence available to guide health-care practice.
Limited evidence from observational and modeling studies suggests that African American men should be screened for prostate cancer. Consideration should be given to initiating screening of African American men at younger ages (eg, 45-50 years) and at more frequent intervals relative to other racial groups in the United States. Screening intervals can be optimized by using a baseline prostate-specific antigen measurement in midlife. Finally, no evidence has indicated that African American men would benefit from screening beyond 75 years of age; in fact, this group may experience higher rates of overdiagnosis at older ages.
The evidence base for prostate cancer screening in African American men is limited by the lack of large, randomized studies. Our literature search supported the need for African American men to be screened for prostate cancer, for initiating screening at younger ages (45-50 years), and perhaps screening at more frequent intervals relative to men of other racial groups in the United States.
African American men are at increased risk of developing prostate cancer, are more likely to be diagnosed with later-stage tumors, and are more likely to die from prostate cancer at higher rates than men of other racial and ethnic groups (1). There is evidence supporting a genetic component to the increased prostate cancer burden among African American men (2-5), but African American men also experience the negative impacts of structural racism on health-care access and quality, are more likely to experience gaps in health insurance coverage, are less likely to receive guideline-concordant care, and present with greater comorbidity at the time of diagnosis (6-11). Thus, there is a need for health-care professionals to provide guidance to African American men who seek prostate cancer screening and early detection.
Although numerous organizations have provided prostate cancer screening guidelines (12,13), these recommendations are limited because of inadequate data to clearly guide implementation. In addition, there is no evidence-guided prostate cancer screening recommendation consensus for African American men. Results from the large, randomized trials of prostate-specific antigen (PSA)–based screening that serve as the primary evidence base for these recommendations have not resolved this issue. The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial reported no benefit from PSA screening on prostate cancer mortality after 17 years of follow-up, although this trial was limited by contamination in the control arm (14). Moreover, only 4% of PLCO participants were African American men, limiting the ability to evaluate the efficacy of PSA-based screening in this population (15). The European Randomized Study of Screening for Prostate Cancer (ERSPC) reported a mortality benefit among screened men after 16 years of follow-up but did not report on participant race and ethnicity (16). Given the higher burden of prostate cancer among African American men, the risks and benefits of PSA-based screening may differ for African American men. Considering the inconclusive evidence underpinning screening recommendations for African American men (13,17), we performed a review of the literature to explore current evidence regarding the need, initiation, cadence, cessation, and appropriate modalities for prostate cancer screening in African American men (12,18).
Methods
Search strategy
We developed a series of 48 patient or population, intervention, comparison, outcomes (PICO) questions (19) addressing critical questions that shape prostate cancer screening guidelines for African American men (Supplementary Table 1, available online). Search terms were then developed in conjunction with a research librarian to address the PICO questions. A search of the PubMed database was conducted in August 2022 using the following search terms:
(("Prostatic Neoplasms/diagnosis"[Mesh] OR "Prostatic Neoplasms/etiology"[Mesh] OR "Prostatic Neoplasms/prevention and control"[Mesh] OR ((prostate[tiab] OR prostatic[tiab]) AND (screening[tiab] OR detect*[tiab] OR diagnos*[tiab]))) AND (Digital rectal[tiab] OR Prostate-specific antigen[tiab] OR PSA[tiab] OR biops*[tiab] OR Biomarker OR Oncotype DX[tiab] OR “Prostate Health Index”[tiab] OR 4Kscore[tiab] OR PCA3[tiab] OR four-kallikrein[tiab] OR PSA glycoforms, TMPRSS2:ERG[tiab] OR microRNA[tiab] OR circulating tumor[tiab] OR androgen receptor[tiab] OR PTEN[tiab] OR mpMRI[tiab] OR bpMRI[tiab] OR “free PSA”[tiab] OR ExoDX[tiab] OR SelectMDX[tiab])) AND (("African Americans"[Mesh] OR "African Continental Ancestry Group"[Mesh] OR African-American*[tiab] OR Black[tiab]) OR African*[tiab]))
No restrictions were applied with respect to study publication date. Searches were limited to studies available in English with inference about US populations. The identified studies used different terms to describe racial identity, including African American, Black, and men of African descent. For consistency, we use African American to describe the study populations represented in the identified studies.
Study evaluation
Search results from PubMed were loaded into Covidence for literature review management. Abstract review was undertaken to identify studies relevant to the proposed PICO questions by 2 independent reviewers (any 2 of R.J., K.H.K., F.M.), with T.R.R. resolving any conflicts. Studies advanced to full-text review were evaluated by any 2 of R.B.J., K.H.K., F.M. In full-text review, studies were rated as having low or high relevance to any of the PICO questions. Studies were included in our analysis if they presented data that addressed 1 or more of the PICO questions. Studies that either full-text reviewer considered relevant were carried forward for extraction and inclusion in the review. The validity of identified studies was evaluated using the McMaster University CLARITY Group Tool to Assess Risk of Bias in Cohort Studies framework (clarityresearch.ca). The level of evidence for each PICO question was assessed using the Oxford Centre for Evidence-Based Medicine levels of evidence (20). Qualitative evaluation of bias for each paper included in this evaluation was undertaken, and a summary bias score was computed. Among the 7 bias criteria considered (Supplementary Table 2, available online), low bias was given a score of 1, moderate bias was given a score of 2, and high bias was given a score of 3. A sum of the 7 bias criteria was computed to give a range of 7 (least bias) to 21 (most bias) for each paper.
Results
A total of 1527 unique studies were identified through PubMed searches in August 2022. Upon abstract review, 1255 studies were not relevant to the PICO questions or did not meet inclusion criteria, while 268 studies were advanced to full-text review. In full-text review, 17 papers were considered highly relevant by at least 1 full-text reviewer (Table 1). Evidence from these highly relevant papers was extracted for inclusion in the review. The papers identified in our search addressed only 5 PICO questions relevant to screening in African American men compared with evidence underpinning current screening recommendations for the total US population. The evidence addressing each question is summarized in Table 2. For all questions that could be addressed here, the strength of evidence was moderate. No randomized clinical trials (RCTs) had sufficient numbers of African American men to draw strong conclusions for any question in the section that follow. Most studies considered here had some level of bias (Supplementary Table 2, available online). For context, we also include the United States Preventive Services Task Force (USPSTF) guidelines in Table 2, but these guidelines did not contribute to or influence the review of the evidence presented here.
| Paper . | Population, design, outcome . | Summary . | PICO question addressed . | Risk of bias summary scorea . |
|---|---|---|---|---|
| Basourakos 2022 (36) |
| Authors used SEER registry data and microsimulation models to estimate the frequency of overdiagnosis and overtreatment. The numbers needed to diagnose and treat were lower for African American men relative to men of all races regardless of modeling approach and assumed benefit of screening. Impact of age on overdiagnosis depended on modeling approach. It was found that mortality benefit accrues over many years, and the magnitude of benefit relative to harm was greater for African American men than for the general population. If half the 270 000 prostate cancer deaths were avoided because of screening, the numbers need to diagnose and treat would be 11-14 and 7-11 for the general population and 8-12 and 5-9 for African American men. Longer follow-up in this study yielded a more favorable risk-benefit ratio associated with screening. | 1 | N/A |
| Catalona 2002 (27) |
| The authors compared the screening results of 3 nonoverlapping groups of men with a positive family history and non–African American men with no known family history. Among high-risk men, the authors examined the percentage of individuals with abnormal screening tests, the positive predictive value of screening tests, cancer detection rates, and the prognostic features of tumors detected. Among high-risk men who were 40-49 years old, there were suspicious screenings in 8%. The probability of being diagnosed with prostate cancer in the SEER program in those aged 40-49 y was about 0.17% overall, including 0.15% in White men and 0.37% in African American men. The authors found that in this study, it was 2%. Of the 8% of men in their 40s who underwent biopsy, the positive predictive value was 55%, and all but 1 was clinically significant. The authors stated that their findings suggest that mortality benefit may result from earlier screening. | 1, 2 | 17 |
| Giri 2009 (30) |
| The authors examined baseline PSA values and longitudinal prediction for prostate cancer by self-reported race and genetic West African ancestry in the Prostate Cancer Risk Assessment Program, a prospective, high-risk cohort. Race and genetic differences by PSA value were not found. For men who had ≥1 follow-up (405 total, 54% African American), 3-y prediction of prostate cancer with a PSA value of 1.5-4.0 ng/mL was higher in African American men with age in the model (P = .025) compared with European American men. Hazard ratios by self-reported race for PSA for prostate cancer were higher among African American men than among European American men (1.59 vs 1.32, P = .04). The authors noted a trend of increasing prediction of PSA for increasing genetic West African ancestry. | 1 | 10 |
| Kim 2017 (71) |
| The purpose of the study was to examine a prespecified prediction model using the 4Kscore to diagnose high-grade prostate cancer using preserved serum samples. These men from the PLCO trial who underwent biopsy for elevated PSA levels (≥4.0 ng/mL), and the authors examined the benefit of another candidate blood biomarker, microseminoprotein-β, in combination with the 4Kscore. The 4Kscore panel model also enhanced high-grade prostate cancer detection over that of PSA (area under the curve = 0.80 vs 0.67). Adjusting for 4Kscore, African American men were almost 3 times more likely than White men to have high-grade prostate cancer. Adjusting for 4Kscore, microseminoprotein-β was a significant predictor of high-grade prostate cancer. The 4Kscore panel also showed greater discrimination in African American men than in men of other races (area under the curve = 0.803 vs 0.781). Finally, the authors found that using 4Kscore as a reflexive modality can decrease unnecessary biopsy. | 5 | 13 |
| Landy 2020 (58) |
| The purpose of this article was to estimate 5-y and 10-y risks of developing aggressive cancer (Gleason ≥8 or stage III/IV). Also, it analyzed the 15-y risks of prostate cancer–specific mortality for Black and White men with baseline PSA values of ≤0.5 ng/mL, ≤1 ng/mL, and 1.01–2.5 ng/mL who were enrolled in the PLCO trial. The authors considered PSA levels ≤0.5 ng/mL as an alternative to PSA levels ≤1 ng/mL for the question of when it may be appropriate to stop screening. A total of 81.2% of men had a baseline PSA value of at least 2.5 ng/mL. It was found that at 5 y, there is no statistically significant difference between races of developing prostate cancer, but at 10 y, African American men had a cumulative incidence of 4.1% (95% CI = 2.2% to 5.9%) and White men had a cumulative incidence of 1.75% (95% CI = 1.52 to 1.98). The authors recommended that men who are at least 65 y old with PSA values of at least 0.5 ng/mL could consider stopping screening. The data support a 5-y screening interval for those who have a PSA level ≤1 ng/mL. | 3, 4 | 17 |
| Loeb 2006 (29) |
| This study explored whether the initial PSA value in men younger than 60 y of age predicts risk of prostate cancer and made comparisons with other risk factors. For digital rectal examination findings, being African American and having a family history of prostate cancer were associated with a 4.9-fold, 1.2-fold, and 1.06-fold increased risk of prostate cancer, respectively. The median PSA level was 0.7 ng/mL for men aged 40-49 y and 0.9 ng/mL for men aged 50-59 y. A baseline PSA level between the median value and 2.5 ng/mL was associated with a 14.6-fold and 7.6-fold increased risk of prostate cancer in men aged 40-49 y and 50-59 y, respectively. | 1, 2 | 20 |
| Loeb 2007 (28) |
| The authors sought to understand the appropriate screening strategy for men with a PSA level less than the age-specific median: 0.7 ng/mL. They found that men aged 40-49 y with a PSA value less than the age-specific median have a low risk of prostate cancer in the short term. Men in their 40s with a baseline above the age-specific median were more likely to have a prostate-specific antigen velocity of 0.75 ng/mL per year and be diagnosed with prostate cancer. Baseline PSA value is a greater predictor of cancer risk than race or family history. The authors asserted that a PSA measure in a man’s 40s can be used to inform subsequent screening. | 1-3 | 19 |
| Miller 2018 (34) |
| Although the PLCO was underpowered to detect differences in prostate cancer mortality by race, the authors examined differences in secondary outcomes (aggressive tumor incidence, false positives, biopsy follow-up). African American men were more likely to have PSA false-positive results (14.5% vs 12.4%; P = .02) but less likely to have digital rectal examination false-positive results (10.9% vs 14.2%; P < .001). African American men were more likely to undergo a biopsy, but there was no difference when restricting to men with abnormal screening results. Rates of overdiagnosis did not statistically significantly differ by race. African American men were statistically significantly more likely to be diagnosed with metastatic prostate cancer (6.4% and 8.7% vs 3.2% and 3.6% respectively). The findings are consistent with previous studies. | 1 | 13 |
| Nyame 2021 (48) |
| The authors used 2 microsimulation models to examine the impact of different screening regimens on mean lead time and overdiagnosis. Models did not provide evidence of differential lead time associated with screening for African American men (∼3 y), but the rate of overdiagnosis was higher among African American men. The authors suggested that annual screening for men aged 45-69 y is the optimal balance of benefits and harms for African American men, leading to a mortality reduction of 26%-29% while limiting overdiagnosis to 51-61 per 1000 men. If annual screening were applied without age limit, mortality reduction was increased to 29%-31% but overdiagnosis ballooned to 112-129 per 1000 men. | 1-4 | N/A |
| Preston 2019 (31) |
| The purpose of this study was to determine whether baseline PSA level during midlife predicts the risk of aggressive prostate cancer in African American men. Median PSA among control men was 0.72, 0.80, 0.94, and 1.03 ng/mL for the age groups 40-49 y, 50-54 y, 55-59 y, and 60-64 y, respectively; 90th percentile levels were 1.68, 1.85, 2.73, and 3.33 ng/mL. The authors found that PSA levels in midlife strongly predicted subsequent development of aggressive prostate cancer; 95% of men who developed prostate cancer and 97% of men who developed aggressive prostate cancer had a baseline PSA value above the age-specific median. In men with PSA levels greater than the median vs less than or equal to the median, the odds ratio for aggressive prostate cancer was 49.6 (95% CI = 10.8 to infinity) for men aged 40-54 y. PSA levels from 1 to 3 ng/mL were indicative of large increases in risk, with few prostate cancer cases occurring among men with levels <1 ng/mL. | 1-3 | 10 |
| Qiao 2022 (47) |
| The authors purported that there is an absence of information and research about screening practices specific to African American men, so they created a retrospective cohort through the VA. This was a retrospective analysis of screening practices of African American male veterans through the VA system aged 40-55 y diagnosed with prostate cancer between 2004 and 2017. The authors then calculated the percentage of annual PSA screening 5 y before diagnosis; 5.4% of patients received annual PSA screenings, 22.4% received no prior PSA screening, 36.5% had annual visits, and 10.2% had no annual visits. The correlation between primary care professional visits and PSA testing was 0.68 (P < .001). Patients without previous PSA testing had higher PSA values, higher frequency of Gleason score ≥8 tumors, and higher rates of metastatic disease. Men with ≥1 PSA screenings had 44% lower odds of having a PSA value >20 ng/mL, 22% lower odds of having a Gleason score ≥8 tumor, and 50% lower odds of having metastatic disease at diagnosis. Patients with prior PSA screening had lower cumulative incidence of prostate cancer–specific mortality at median follow-up. PSA screening improved prostate cancer outcomes for patients. | 1, 2 | 9 |
| Sherer 2022 (56) |
| This VA-based retrospective cohort studied 45 834 men and analyzed the association between PSA screening and risk of prostate cancer–specific mortality. The authors also analyzed screening practices leading up to diagnosis. The average age of the study population was 62.7 y, and 31% of patients were non-Hispanic Black. PSA screening rate was associated with lower risk of prostate cancer–specific mortality among non-Hispanic Black men (subdistribution hazard ratio = 0.56, 95% CI = 0.41 to 0.76, P = .001). Annual screening vs “some” screening was statistically significant in decreasing risk for the non-Hispanic Black population (subdistribution hazard ratio = 0.65, 95% CI = 0.46 to 0.92, P = .02) but not for the non-Hispanic White population. The authors found that annual PSA screening is important for reducing prostate cancer–specific mortality in the non-Hispanic Black community but not in the non-Hispanic White community, suggesting the need for more tailored guidelines for screening practices. | 1, 3 | 15 |
| Tang 2010 (57) |
| The purpose of this study was to learn whether baseline PSA can be used to stratify patients and predict risk of death from prostate cancer and death from all causes in the population targeted for PSA measurement. Multivariate findings included those men with a baseline PSA of 4.0-9.9 ng/mL and 10 ng/mL were found to have a 3.0-fold and 11.5-fold higher rate of death from prostate cancer, respectively, compared with men with a baseline PSA value <2.5 ng/mL. Having a baseline PSA value of 10 ng/mL predicted death from prostate cancer with 77% sensitivity and 78% specificity. Being African American and at advanced age at the time of baseline PSA measurement was associated with a higher rate of death from prostate cancer and death from all causes. | 1, 3 | 17 |
| Telesca 2008 (35) |
| The authors gathered information about the increase and decline in prostate cancer incidence following the adoption of PSA testing to estimate the lead time associated with PSA screening. They found that an average lead time of approximately 4.59 y for European Americans and 6.78 y for African Americans with a corresponding secular trend that was flattened after the introduction of PSA screening. The authors concluded that if PSA screening had not occurred, the incidence of prostate cancer would not have increased, but prostate patterns of care unrelated to PSA would have leveled off. | 1, 2, 4 | N/A |
| Tsodikov 2017 (46) |
| Tsodikov and colleagues calibrated 3 natural history models of prostate cancer to observed incidence data in SEER given a construction of national screening trends based on the National Health Interview Survey and SEER-Medicare data. Absolute risk of developing preclinical disease is 30%-43% among African American men (higher than ∼25% in all men). Among men with disease onset, risk of clinical diagnosis does not differ by race, but risk of metastatic disease before diagnosis was higher among African American men, 44%-75% higher than the general population. Assuming that screening should begin at 55 y of age generally, African American men reach risk threshold for relevant disease 3-9 y earlier than their counterparts from other races. | 1-4 | N/A |
| Whittemore 1995 (33) |
| The purpose of this study was to evaluate serum PSA levels and subsequent prostate cancer occurrence in a cohort of young African American and White men. Using cohort data from Kaiser Permanente Medical Care Plan of Northern California, the authors analyzed serial PSA concentrations in sera collected from 136 men (40 African American men and 96 White men) who were subsequently diagnosed with histologically confirmed prostate cancer and from 184 men (84 African American men and 100 White men) without subsequent diagnosis of prostate cancer. There were no statistically significant differences in the performance of the markers by race. High-risk prostate cancer cutoff was defined as if last PSA concentration exceeded 7.3 (4.0) ng/mL, regardless of the man’s age. | 1, 3 | 13 |
| Whittemore 2005 (32) |
| The purpose of this study was to examine the associations between PSA levels in young adulthood and subsequent prostate cancer risk using a nested case-control design. For the reported associations of baseline PSA levels in subgroups of matched case-control sets defined by race, age at risk for prostate cancer, and case diagnosis year, African American men who were younger than 65 y of age were 7.4 times more likely than the control group to have a PSA level ≥0.56 ng/mL. As it relates to screening recommendations for prostate cancer in men younger than 65 y of age, it may be best to monitor those with increased PSA levels and perform biopsy when levels start to increase consistently at a rate exceeding some critical value because the biopsy process is psychologically burdensome for some men. | 1, 3 | 17 |
| Paper . | Population, design, outcome . | Summary . | PICO question addressed . | Risk of bias summary scorea . |
|---|---|---|---|---|
| Basourakos 2022 (36) |
| Authors used SEER registry data and microsimulation models to estimate the frequency of overdiagnosis and overtreatment. The numbers needed to diagnose and treat were lower for African American men relative to men of all races regardless of modeling approach and assumed benefit of screening. Impact of age on overdiagnosis depended on modeling approach. It was found that mortality benefit accrues over many years, and the magnitude of benefit relative to harm was greater for African American men than for the general population. If half the 270 000 prostate cancer deaths were avoided because of screening, the numbers need to diagnose and treat would be 11-14 and 7-11 for the general population and 8-12 and 5-9 for African American men. Longer follow-up in this study yielded a more favorable risk-benefit ratio associated with screening. | 1 | N/A |
| Catalona 2002 (27) |
| The authors compared the screening results of 3 nonoverlapping groups of men with a positive family history and non–African American men with no known family history. Among high-risk men, the authors examined the percentage of individuals with abnormal screening tests, the positive predictive value of screening tests, cancer detection rates, and the prognostic features of tumors detected. Among high-risk men who were 40-49 years old, there were suspicious screenings in 8%. The probability of being diagnosed with prostate cancer in the SEER program in those aged 40-49 y was about 0.17% overall, including 0.15% in White men and 0.37% in African American men. The authors found that in this study, it was 2%. Of the 8% of men in their 40s who underwent biopsy, the positive predictive value was 55%, and all but 1 was clinically significant. The authors stated that their findings suggest that mortality benefit may result from earlier screening. | 1, 2 | 17 |
| Giri 2009 (30) |
| The authors examined baseline PSA values and longitudinal prediction for prostate cancer by self-reported race and genetic West African ancestry in the Prostate Cancer Risk Assessment Program, a prospective, high-risk cohort. Race and genetic differences by PSA value were not found. For men who had ≥1 follow-up (405 total, 54% African American), 3-y prediction of prostate cancer with a PSA value of 1.5-4.0 ng/mL was higher in African American men with age in the model (P = .025) compared with European American men. Hazard ratios by self-reported race for PSA for prostate cancer were higher among African American men than among European American men (1.59 vs 1.32, P = .04). The authors noted a trend of increasing prediction of PSA for increasing genetic West African ancestry. | 1 | 10 |
| Kim 2017 (71) |
| The purpose of the study was to examine a prespecified prediction model using the 4Kscore to diagnose high-grade prostate cancer using preserved serum samples. These men from the PLCO trial who underwent biopsy for elevated PSA levels (≥4.0 ng/mL), and the authors examined the benefit of another candidate blood biomarker, microseminoprotein-β, in combination with the 4Kscore. The 4Kscore panel model also enhanced high-grade prostate cancer detection over that of PSA (area under the curve = 0.80 vs 0.67). Adjusting for 4Kscore, African American men were almost 3 times more likely than White men to have high-grade prostate cancer. Adjusting for 4Kscore, microseminoprotein-β was a significant predictor of high-grade prostate cancer. The 4Kscore panel also showed greater discrimination in African American men than in men of other races (area under the curve = 0.803 vs 0.781). Finally, the authors found that using 4Kscore as a reflexive modality can decrease unnecessary biopsy. | 5 | 13 |
| Landy 2020 (58) |
| The purpose of this article was to estimate 5-y and 10-y risks of developing aggressive cancer (Gleason ≥8 or stage III/IV). Also, it analyzed the 15-y risks of prostate cancer–specific mortality for Black and White men with baseline PSA values of ≤0.5 ng/mL, ≤1 ng/mL, and 1.01–2.5 ng/mL who were enrolled in the PLCO trial. The authors considered PSA levels ≤0.5 ng/mL as an alternative to PSA levels ≤1 ng/mL for the question of when it may be appropriate to stop screening. A total of 81.2% of men had a baseline PSA value of at least 2.5 ng/mL. It was found that at 5 y, there is no statistically significant difference between races of developing prostate cancer, but at 10 y, African American men had a cumulative incidence of 4.1% (95% CI = 2.2% to 5.9%) and White men had a cumulative incidence of 1.75% (95% CI = 1.52 to 1.98). The authors recommended that men who are at least 65 y old with PSA values of at least 0.5 ng/mL could consider stopping screening. The data support a 5-y screening interval for those who have a PSA level ≤1 ng/mL. | 3, 4 | 17 |
| Loeb 2006 (29) |
| This study explored whether the initial PSA value in men younger than 60 y of age predicts risk of prostate cancer and made comparisons with other risk factors. For digital rectal examination findings, being African American and having a family history of prostate cancer were associated with a 4.9-fold, 1.2-fold, and 1.06-fold increased risk of prostate cancer, respectively. The median PSA level was 0.7 ng/mL for men aged 40-49 y and 0.9 ng/mL for men aged 50-59 y. A baseline PSA level between the median value and 2.5 ng/mL was associated with a 14.6-fold and 7.6-fold increased risk of prostate cancer in men aged 40-49 y and 50-59 y, respectively. | 1, 2 | 20 |
| Loeb 2007 (28) |
| The authors sought to understand the appropriate screening strategy for men with a PSA level less than the age-specific median: 0.7 ng/mL. They found that men aged 40-49 y with a PSA value less than the age-specific median have a low risk of prostate cancer in the short term. Men in their 40s with a baseline above the age-specific median were more likely to have a prostate-specific antigen velocity of 0.75 ng/mL per year and be diagnosed with prostate cancer. Baseline PSA value is a greater predictor of cancer risk than race or family history. The authors asserted that a PSA measure in a man’s 40s can be used to inform subsequent screening. | 1-3 | 19 |
| Miller 2018 (34) |
| Although the PLCO was underpowered to detect differences in prostate cancer mortality by race, the authors examined differences in secondary outcomes (aggressive tumor incidence, false positives, biopsy follow-up). African American men were more likely to have PSA false-positive results (14.5% vs 12.4%; P = .02) but less likely to have digital rectal examination false-positive results (10.9% vs 14.2%; P < .001). African American men were more likely to undergo a biopsy, but there was no difference when restricting to men with abnormal screening results. Rates of overdiagnosis did not statistically significantly differ by race. African American men were statistically significantly more likely to be diagnosed with metastatic prostate cancer (6.4% and 8.7% vs 3.2% and 3.6% respectively). The findings are consistent with previous studies. | 1 | 13 |
| Nyame 2021 (48) |
| The authors used 2 microsimulation models to examine the impact of different screening regimens on mean lead time and overdiagnosis. Models did not provide evidence of differential lead time associated with screening for African American men (∼3 y), but the rate of overdiagnosis was higher among African American men. The authors suggested that annual screening for men aged 45-69 y is the optimal balance of benefits and harms for African American men, leading to a mortality reduction of 26%-29% while limiting overdiagnosis to 51-61 per 1000 men. If annual screening were applied without age limit, mortality reduction was increased to 29%-31% but overdiagnosis ballooned to 112-129 per 1000 men. | 1-4 | N/A |
| Preston 2019 (31) |
| The purpose of this study was to determine whether baseline PSA level during midlife predicts the risk of aggressive prostate cancer in African American men. Median PSA among control men was 0.72, 0.80, 0.94, and 1.03 ng/mL for the age groups 40-49 y, 50-54 y, 55-59 y, and 60-64 y, respectively; 90th percentile levels were 1.68, 1.85, 2.73, and 3.33 ng/mL. The authors found that PSA levels in midlife strongly predicted subsequent development of aggressive prostate cancer; 95% of men who developed prostate cancer and 97% of men who developed aggressive prostate cancer had a baseline PSA value above the age-specific median. In men with PSA levels greater than the median vs less than or equal to the median, the odds ratio for aggressive prostate cancer was 49.6 (95% CI = 10.8 to infinity) for men aged 40-54 y. PSA levels from 1 to 3 ng/mL were indicative of large increases in risk, with few prostate cancer cases occurring among men with levels <1 ng/mL. | 1-3 | 10 |
| Qiao 2022 (47) |
| The authors purported that there is an absence of information and research about screening practices specific to African American men, so they created a retrospective cohort through the VA. This was a retrospective analysis of screening practices of African American male veterans through the VA system aged 40-55 y diagnosed with prostate cancer between 2004 and 2017. The authors then calculated the percentage of annual PSA screening 5 y before diagnosis; 5.4% of patients received annual PSA screenings, 22.4% received no prior PSA screening, 36.5% had annual visits, and 10.2% had no annual visits. The correlation between primary care professional visits and PSA testing was 0.68 (P < .001). Patients without previous PSA testing had higher PSA values, higher frequency of Gleason score ≥8 tumors, and higher rates of metastatic disease. Men with ≥1 PSA screenings had 44% lower odds of having a PSA value >20 ng/mL, 22% lower odds of having a Gleason score ≥8 tumor, and 50% lower odds of having metastatic disease at diagnosis. Patients with prior PSA screening had lower cumulative incidence of prostate cancer–specific mortality at median follow-up. PSA screening improved prostate cancer outcomes for patients. | 1, 2 | 9 |
| Sherer 2022 (56) |
| This VA-based retrospective cohort studied 45 834 men and analyzed the association between PSA screening and risk of prostate cancer–specific mortality. The authors also analyzed screening practices leading up to diagnosis. The average age of the study population was 62.7 y, and 31% of patients were non-Hispanic Black. PSA screening rate was associated with lower risk of prostate cancer–specific mortality among non-Hispanic Black men (subdistribution hazard ratio = 0.56, 95% CI = 0.41 to 0.76, P = .001). Annual screening vs “some” screening was statistically significant in decreasing risk for the non-Hispanic Black population (subdistribution hazard ratio = 0.65, 95% CI = 0.46 to 0.92, P = .02) but not for the non-Hispanic White population. The authors found that annual PSA screening is important for reducing prostate cancer–specific mortality in the non-Hispanic Black community but not in the non-Hispanic White community, suggesting the need for more tailored guidelines for screening practices. | 1, 3 | 15 |
| Tang 2010 (57) |
| The purpose of this study was to learn whether baseline PSA can be used to stratify patients and predict risk of death from prostate cancer and death from all causes in the population targeted for PSA measurement. Multivariate findings included those men with a baseline PSA of 4.0-9.9 ng/mL and 10 ng/mL were found to have a 3.0-fold and 11.5-fold higher rate of death from prostate cancer, respectively, compared with men with a baseline PSA value <2.5 ng/mL. Having a baseline PSA value of 10 ng/mL predicted death from prostate cancer with 77% sensitivity and 78% specificity. Being African American and at advanced age at the time of baseline PSA measurement was associated with a higher rate of death from prostate cancer and death from all causes. | 1, 3 | 17 |
| Telesca 2008 (35) |
| The authors gathered information about the increase and decline in prostate cancer incidence following the adoption of PSA testing to estimate the lead time associated with PSA screening. They found that an average lead time of approximately 4.59 y for European Americans and 6.78 y for African Americans with a corresponding secular trend that was flattened after the introduction of PSA screening. The authors concluded that if PSA screening had not occurred, the incidence of prostate cancer would not have increased, but prostate patterns of care unrelated to PSA would have leveled off. | 1, 2, 4 | N/A |
| Tsodikov 2017 (46) |
| Tsodikov and colleagues calibrated 3 natural history models of prostate cancer to observed incidence data in SEER given a construction of national screening trends based on the National Health Interview Survey and SEER-Medicare data. Absolute risk of developing preclinical disease is 30%-43% among African American men (higher than ∼25% in all men). Among men with disease onset, risk of clinical diagnosis does not differ by race, but risk of metastatic disease before diagnosis was higher among African American men, 44%-75% higher than the general population. Assuming that screening should begin at 55 y of age generally, African American men reach risk threshold for relevant disease 3-9 y earlier than their counterparts from other races. | 1-4 | N/A |
| Whittemore 1995 (33) |
| The purpose of this study was to evaluate serum PSA levels and subsequent prostate cancer occurrence in a cohort of young African American and White men. Using cohort data from Kaiser Permanente Medical Care Plan of Northern California, the authors analyzed serial PSA concentrations in sera collected from 136 men (40 African American men and 96 White men) who were subsequently diagnosed with histologically confirmed prostate cancer and from 184 men (84 African American men and 100 White men) without subsequent diagnosis of prostate cancer. There were no statistically significant differences in the performance of the markers by race. High-risk prostate cancer cutoff was defined as if last PSA concentration exceeded 7.3 (4.0) ng/mL, regardless of the man’s age. | 1, 3 | 13 |
| Whittemore 2005 (32) |
| The purpose of this study was to examine the associations between PSA levels in young adulthood and subsequent prostate cancer risk using a nested case-control design. For the reported associations of baseline PSA levels in subgroups of matched case-control sets defined by race, age at risk for prostate cancer, and case diagnosis year, African American men who were younger than 65 y of age were 7.4 times more likely than the control group to have a PSA level ≥0.56 ng/mL. As it relates to screening recommendations for prostate cancer in men younger than 65 y of age, it may be best to monitor those with increased PSA levels and perform biopsy when levels start to increase consistently at a rate exceeding some critical value because the biopsy process is psychologically burdensome for some men. | 1, 3 | 17 |
Risk of bias summary score ranged from 7 to 21 and were not determined for modeling studies (see Supplementary Table 2, available online). CAP = Cluster Randomized Trial of PSA Testing for Prostate Cancer; CI = confidence interval; N/A = not applicable; PLCC = Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial; PSA = prostate-specific antigen; SEER = Surveillance, Epidemiology, and End Results program; VA = US Department of Veterans Affairs.
| Paper . | Population, design, outcome . | Summary . | PICO question addressed . | Risk of bias summary scorea . |
|---|---|---|---|---|
| Basourakos 2022 (36) |
| Authors used SEER registry data and microsimulation models to estimate the frequency of overdiagnosis and overtreatment. The numbers needed to diagnose and treat were lower for African American men relative to men of all races regardless of modeling approach and assumed benefit of screening. Impact of age on overdiagnosis depended on modeling approach. It was found that mortality benefit accrues over many years, and the magnitude of benefit relative to harm was greater for African American men than for the general population. If half the 270 000 prostate cancer deaths were avoided because of screening, the numbers need to diagnose and treat would be 11-14 and 7-11 for the general population and 8-12 and 5-9 for African American men. Longer follow-up in this study yielded a more favorable risk-benefit ratio associated with screening. | 1 | N/A |
| Catalona 2002 (27) |
| The authors compared the screening results of 3 nonoverlapping groups of men with a positive family history and non–African American men with no known family history. Among high-risk men, the authors examined the percentage of individuals with abnormal screening tests, the positive predictive value of screening tests, cancer detection rates, and the prognostic features of tumors detected. Among high-risk men who were 40-49 years old, there were suspicious screenings in 8%. The probability of being diagnosed with prostate cancer in the SEER program in those aged 40-49 y was about 0.17% overall, including 0.15% in White men and 0.37% in African American men. The authors found that in this study, it was 2%. Of the 8% of men in their 40s who underwent biopsy, the positive predictive value was 55%, and all but 1 was clinically significant. The authors stated that their findings suggest that mortality benefit may result from earlier screening. | 1, 2 | 17 |
| Giri 2009 (30) |
| The authors examined baseline PSA values and longitudinal prediction for prostate cancer by self-reported race and genetic West African ancestry in the Prostate Cancer Risk Assessment Program, a prospective, high-risk cohort. Race and genetic differences by PSA value were not found. For men who had ≥1 follow-up (405 total, 54% African American), 3-y prediction of prostate cancer with a PSA value of 1.5-4.0 ng/mL was higher in African American men with age in the model (P = .025) compared with European American men. Hazard ratios by self-reported race for PSA for prostate cancer were higher among African American men than among European American men (1.59 vs 1.32, P = .04). The authors noted a trend of increasing prediction of PSA for increasing genetic West African ancestry. | 1 | 10 |
| Kim 2017 (71) |
| The purpose of the study was to examine a prespecified prediction model using the 4Kscore to diagnose high-grade prostate cancer using preserved serum samples. These men from the PLCO trial who underwent biopsy for elevated PSA levels (≥4.0 ng/mL), and the authors examined the benefit of another candidate blood biomarker, microseminoprotein-β, in combination with the 4Kscore. The 4Kscore panel model also enhanced high-grade prostate cancer detection over that of PSA (area under the curve = 0.80 vs 0.67). Adjusting for 4Kscore, African American men were almost 3 times more likely than White men to have high-grade prostate cancer. Adjusting for 4Kscore, microseminoprotein-β was a significant predictor of high-grade prostate cancer. The 4Kscore panel also showed greater discrimination in African American men than in men of other races (area under the curve = 0.803 vs 0.781). Finally, the authors found that using 4Kscore as a reflexive modality can decrease unnecessary biopsy. | 5 | 13 |
| Landy 2020 (58) |
| The purpose of this article was to estimate 5-y and 10-y risks of developing aggressive cancer (Gleason ≥8 or stage III/IV). Also, it analyzed the 15-y risks of prostate cancer–specific mortality for Black and White men with baseline PSA values of ≤0.5 ng/mL, ≤1 ng/mL, and 1.01–2.5 ng/mL who were enrolled in the PLCO trial. The authors considered PSA levels ≤0.5 ng/mL as an alternative to PSA levels ≤1 ng/mL for the question of when it may be appropriate to stop screening. A total of 81.2% of men had a baseline PSA value of at least 2.5 ng/mL. It was found that at 5 y, there is no statistically significant difference between races of developing prostate cancer, but at 10 y, African American men had a cumulative incidence of 4.1% (95% CI = 2.2% to 5.9%) and White men had a cumulative incidence of 1.75% (95% CI = 1.52 to 1.98). The authors recommended that men who are at least 65 y old with PSA values of at least 0.5 ng/mL could consider stopping screening. The data support a 5-y screening interval for those who have a PSA level ≤1 ng/mL. | 3, 4 | 17 |
| Loeb 2006 (29) |
| This study explored whether the initial PSA value in men younger than 60 y of age predicts risk of prostate cancer and made comparisons with other risk factors. For digital rectal examination findings, being African American and having a family history of prostate cancer were associated with a 4.9-fold, 1.2-fold, and 1.06-fold increased risk of prostate cancer, respectively. The median PSA level was 0.7 ng/mL for men aged 40-49 y and 0.9 ng/mL for men aged 50-59 y. A baseline PSA level between the median value and 2.5 ng/mL was associated with a 14.6-fold and 7.6-fold increased risk of prostate cancer in men aged 40-49 y and 50-59 y, respectively. | 1, 2 | 20 |
| Loeb 2007 (28) |
| The authors sought to understand the appropriate screening strategy for men with a PSA level less than the age-specific median: 0.7 ng/mL. They found that men aged 40-49 y with a PSA value less than the age-specific median have a low risk of prostate cancer in the short term. Men in their 40s with a baseline above the age-specific median were more likely to have a prostate-specific antigen velocity of 0.75 ng/mL per year and be diagnosed with prostate cancer. Baseline PSA value is a greater predictor of cancer risk than race or family history. The authors asserted that a PSA measure in a man’s 40s can be used to inform subsequent screening. | 1-3 | 19 |
| Miller 2018 (34) |
| Although the PLCO was underpowered to detect differences in prostate cancer mortality by race, the authors examined differences in secondary outcomes (aggressive tumor incidence, false positives, biopsy follow-up). African American men were more likely to have PSA false-positive results (14.5% vs 12.4%; P = .02) but less likely to have digital rectal examination false-positive results (10.9% vs 14.2%; P < .001). African American men were more likely to undergo a biopsy, but there was no difference when restricting to men with abnormal screening results. Rates of overdiagnosis did not statistically significantly differ by race. African American men were statistically significantly more likely to be diagnosed with metastatic prostate cancer (6.4% and 8.7% vs 3.2% and 3.6% respectively). The findings are consistent with previous studies. | 1 | 13 |
| Nyame 2021 (48) |
| The authors used 2 microsimulation models to examine the impact of different screening regimens on mean lead time and overdiagnosis. Models did not provide evidence of differential lead time associated with screening for African American men (∼3 y), but the rate of overdiagnosis was higher among African American men. The authors suggested that annual screening for men aged 45-69 y is the optimal balance of benefits and harms for African American men, leading to a mortality reduction of 26%-29% while limiting overdiagnosis to 51-61 per 1000 men. If annual screening were applied without age limit, mortality reduction was increased to 29%-31% but overdiagnosis ballooned to 112-129 per 1000 men. | 1-4 | N/A |
| Preston 2019 (31) |
| The purpose of this study was to determine whether baseline PSA level during midlife predicts the risk of aggressive prostate cancer in African American men. Median PSA among control men was 0.72, 0.80, 0.94, and 1.03 ng/mL for the age groups 40-49 y, 50-54 y, 55-59 y, and 60-64 y, respectively; 90th percentile levels were 1.68, 1.85, 2.73, and 3.33 ng/mL. The authors found that PSA levels in midlife strongly predicted subsequent development of aggressive prostate cancer; 95% of men who developed prostate cancer and 97% of men who developed aggressive prostate cancer had a baseline PSA value above the age-specific median. In men with PSA levels greater than the median vs less than or equal to the median, the odds ratio for aggressive prostate cancer was 49.6 (95% CI = 10.8 to infinity) for men aged 40-54 y. PSA levels from 1 to 3 ng/mL were indicative of large increases in risk, with few prostate cancer cases occurring among men with levels <1 ng/mL. | 1-3 | 10 |
| Qiao 2022 (47) |
| The authors purported that there is an absence of information and research about screening practices specific to African American men, so they created a retrospective cohort through the VA. This was a retrospective analysis of screening practices of African American male veterans through the VA system aged 40-55 y diagnosed with prostate cancer between 2004 and 2017. The authors then calculated the percentage of annual PSA screening 5 y before diagnosis; 5.4% of patients received annual PSA screenings, 22.4% received no prior PSA screening, 36.5% had annual visits, and 10.2% had no annual visits. The correlation between primary care professional visits and PSA testing was 0.68 (P < .001). Patients without previous PSA testing had higher PSA values, higher frequency of Gleason score ≥8 tumors, and higher rates of metastatic disease. Men with ≥1 PSA screenings had 44% lower odds of having a PSA value >20 ng/mL, 22% lower odds of having a Gleason score ≥8 tumor, and 50% lower odds of having metastatic disease at diagnosis. Patients with prior PSA screening had lower cumulative incidence of prostate cancer–specific mortality at median follow-up. PSA screening improved prostate cancer outcomes for patients. | 1, 2 | 9 |
| Sherer 2022 (56) |
| This VA-based retrospective cohort studied 45 834 men and analyzed the association between PSA screening and risk of prostate cancer–specific mortality. The authors also analyzed screening practices leading up to diagnosis. The average age of the study population was 62.7 y, and 31% of patients were non-Hispanic Black. PSA screening rate was associated with lower risk of prostate cancer–specific mortality among non-Hispanic Black men (subdistribution hazard ratio = 0.56, 95% CI = 0.41 to 0.76, P = .001). Annual screening vs “some” screening was statistically significant in decreasing risk for the non-Hispanic Black population (subdistribution hazard ratio = 0.65, 95% CI = 0.46 to 0.92, P = .02) but not for the non-Hispanic White population. The authors found that annual PSA screening is important for reducing prostate cancer–specific mortality in the non-Hispanic Black community but not in the non-Hispanic White community, suggesting the need for more tailored guidelines for screening practices. | 1, 3 | 15 |
| Tang 2010 (57) |
| The purpose of this study was to learn whether baseline PSA can be used to stratify patients and predict risk of death from prostate cancer and death from all causes in the population targeted for PSA measurement. Multivariate findings included those men with a baseline PSA of 4.0-9.9 ng/mL and 10 ng/mL were found to have a 3.0-fold and 11.5-fold higher rate of death from prostate cancer, respectively, compared with men with a baseline PSA value <2.5 ng/mL. Having a baseline PSA value of 10 ng/mL predicted death from prostate cancer with 77% sensitivity and 78% specificity. Being African American and at advanced age at the time of baseline PSA measurement was associated with a higher rate of death from prostate cancer and death from all causes. | 1, 3 | 17 |
| Telesca 2008 (35) |
| The authors gathered information about the increase and decline in prostate cancer incidence following the adoption of PSA testing to estimate the lead time associated with PSA screening. They found that an average lead time of approximately 4.59 y for European Americans and 6.78 y for African Americans with a corresponding secular trend that was flattened after the introduction of PSA screening. The authors concluded that if PSA screening had not occurred, the incidence of prostate cancer would not have increased, but prostate patterns of care unrelated to PSA would have leveled off. | 1, 2, 4 | N/A |
| Tsodikov 2017 (46) |
| Tsodikov and colleagues calibrated 3 natural history models of prostate cancer to observed incidence data in SEER given a construction of national screening trends based on the National Health Interview Survey and SEER-Medicare data. Absolute risk of developing preclinical disease is 30%-43% among African American men (higher than ∼25% in all men). Among men with disease onset, risk of clinical diagnosis does not differ by race, but risk of metastatic disease before diagnosis was higher among African American men, 44%-75% higher than the general population. Assuming that screening should begin at 55 y of age generally, African American men reach risk threshold for relevant disease 3-9 y earlier than their counterparts from other races. | 1-4 | N/A |
| Whittemore 1995 (33) |
| The purpose of this study was to evaluate serum PSA levels and subsequent prostate cancer occurrence in a cohort of young African American and White men. Using cohort data from Kaiser Permanente Medical Care Plan of Northern California, the authors analyzed serial PSA concentrations in sera collected from 136 men (40 African American men and 96 White men) who were subsequently diagnosed with histologically confirmed prostate cancer and from 184 men (84 African American men and 100 White men) without subsequent diagnosis of prostate cancer. There were no statistically significant differences in the performance of the markers by race. High-risk prostate cancer cutoff was defined as if last PSA concentration exceeded 7.3 (4.0) ng/mL, regardless of the man’s age. | 1, 3 | 13 |
| Whittemore 2005 (32) |
| The purpose of this study was to examine the associations between PSA levels in young adulthood and subsequent prostate cancer risk using a nested case-control design. For the reported associations of baseline PSA levels in subgroups of matched case-control sets defined by race, age at risk for prostate cancer, and case diagnosis year, African American men who were younger than 65 y of age were 7.4 times more likely than the control group to have a PSA level ≥0.56 ng/mL. As it relates to screening recommendations for prostate cancer in men younger than 65 y of age, it may be best to monitor those with increased PSA levels and perform biopsy when levels start to increase consistently at a rate exceeding some critical value because the biopsy process is psychologically burdensome for some men. | 1, 3 | 17 |
| Paper . | Population, design, outcome . | Summary . | PICO question addressed . | Risk of bias summary scorea . |
|---|---|---|---|---|
| Basourakos 2022 (36) |
| Authors used SEER registry data and microsimulation models to estimate the frequency of overdiagnosis and overtreatment. The numbers needed to diagnose and treat were lower for African American men relative to men of all races regardless of modeling approach and assumed benefit of screening. Impact of age on overdiagnosis depended on modeling approach. It was found that mortality benefit accrues over many years, and the magnitude of benefit relative to harm was greater for African American men than for the general population. If half the 270 000 prostate cancer deaths were avoided because of screening, the numbers need to diagnose and treat would be 11-14 and 7-11 for the general population and 8-12 and 5-9 for African American men. Longer follow-up in this study yielded a more favorable risk-benefit ratio associated with screening. | 1 | N/A |
| Catalona 2002 (27) |
| The authors compared the screening results of 3 nonoverlapping groups of men with a positive family history and non–African American men with no known family history. Among high-risk men, the authors examined the percentage of individuals with abnormal screening tests, the positive predictive value of screening tests, cancer detection rates, and the prognostic features of tumors detected. Among high-risk men who were 40-49 years old, there were suspicious screenings in 8%. The probability of being diagnosed with prostate cancer in the SEER program in those aged 40-49 y was about 0.17% overall, including 0.15% in White men and 0.37% in African American men. The authors found that in this study, it was 2%. Of the 8% of men in their 40s who underwent biopsy, the positive predictive value was 55%, and all but 1 was clinically significant. The authors stated that their findings suggest that mortality benefit may result from earlier screening. | 1, 2 | 17 |
| Giri 2009 (30) |
| The authors examined baseline PSA values and longitudinal prediction for prostate cancer by self-reported race and genetic West African ancestry in the Prostate Cancer Risk Assessment Program, a prospective, high-risk cohort. Race and genetic differences by PSA value were not found. For men who had ≥1 follow-up (405 total, 54% African American), 3-y prediction of prostate cancer with a PSA value of 1.5-4.0 ng/mL was higher in African American men with age in the model (P = .025) compared with European American men. Hazard ratios by self-reported race for PSA for prostate cancer were higher among African American men than among European American men (1.59 vs 1.32, P = .04). The authors noted a trend of increasing prediction of PSA for increasing genetic West African ancestry. | 1 | 10 |
| Kim 2017 (71) |
| The purpose of the study was to examine a prespecified prediction model using the 4Kscore to diagnose high-grade prostate cancer using preserved serum samples. These men from the PLCO trial who underwent biopsy for elevated PSA levels (≥4.0 ng/mL), and the authors examined the benefit of another candidate blood biomarker, microseminoprotein-β, in combination with the 4Kscore. The 4Kscore panel model also enhanced high-grade prostate cancer detection over that of PSA (area under the curve = 0.80 vs 0.67). Adjusting for 4Kscore, African American men were almost 3 times more likely than White men to have high-grade prostate cancer. Adjusting for 4Kscore, microseminoprotein-β was a significant predictor of high-grade prostate cancer. The 4Kscore panel also showed greater discrimination in African American men than in men of other races (area under the curve = 0.803 vs 0.781). Finally, the authors found that using 4Kscore as a reflexive modality can decrease unnecessary biopsy. | 5 | 13 |
| Landy 2020 (58) |
| The purpose of this article was to estimate 5-y and 10-y risks of developing aggressive cancer (Gleason ≥8 or stage III/IV). Also, it analyzed the 15-y risks of prostate cancer–specific mortality for Black and White men with baseline PSA values of ≤0.5 ng/mL, ≤1 ng/mL, and 1.01–2.5 ng/mL who were enrolled in the PLCO trial. The authors considered PSA levels ≤0.5 ng/mL as an alternative to PSA levels ≤1 ng/mL for the question of when it may be appropriate to stop screening. A total of 81.2% of men had a baseline PSA value of at least 2.5 ng/mL. It was found that at 5 y, there is no statistically significant difference between races of developing prostate cancer, but at 10 y, African American men had a cumulative incidence of 4.1% (95% CI = 2.2% to 5.9%) and White men had a cumulative incidence of 1.75% (95% CI = 1.52 to 1.98). The authors recommended that men who are at least 65 y old with PSA values of at least 0.5 ng/mL could consider stopping screening. The data support a 5-y screening interval for those who have a PSA level ≤1 ng/mL. | 3, 4 | 17 |
| Loeb 2006 (29) |
| This study explored whether the initial PSA value in men younger than 60 y of age predicts risk of prostate cancer and made comparisons with other risk factors. For digital rectal examination findings, being African American and having a family history of prostate cancer were associated with a 4.9-fold, 1.2-fold, and 1.06-fold increased risk of prostate cancer, respectively. The median PSA level was 0.7 ng/mL for men aged 40-49 y and 0.9 ng/mL for men aged 50-59 y. A baseline PSA level between the median value and 2.5 ng/mL was associated with a 14.6-fold and 7.6-fold increased risk of prostate cancer in men aged 40-49 y and 50-59 y, respectively. | 1, 2 | 20 |
| Loeb 2007 (28) |
| The authors sought to understand the appropriate screening strategy for men with a PSA level less than the age-specific median: 0.7 ng/mL. They found that men aged 40-49 y with a PSA value less than the age-specific median have a low risk of prostate cancer in the short term. Men in their 40s with a baseline above the age-specific median were more likely to have a prostate-specific antigen velocity of 0.75 ng/mL per year and be diagnosed with prostate cancer. Baseline PSA value is a greater predictor of cancer risk than race or family history. The authors asserted that a PSA measure in a man’s 40s can be used to inform subsequent screening. | 1-3 | 19 |
| Miller 2018 (34) |
| Although the PLCO was underpowered to detect differences in prostate cancer mortality by race, the authors examined differences in secondary outcomes (aggressive tumor incidence, false positives, biopsy follow-up). African American men were more likely to have PSA false-positive results (14.5% vs 12.4%; P = .02) but less likely to have digital rectal examination false-positive results (10.9% vs 14.2%; P < .001). African American men were more likely to undergo a biopsy, but there was no difference when restricting to men with abnormal screening results. Rates of overdiagnosis did not statistically significantly differ by race. African American men were statistically significantly more likely to be diagnosed with metastatic prostate cancer (6.4% and 8.7% vs 3.2% and 3.6% respectively). The findings are consistent with previous studies. | 1 | 13 |
| Nyame 2021 (48) |
| The authors used 2 microsimulation models to examine the impact of different screening regimens on mean lead time and overdiagnosis. Models did not provide evidence of differential lead time associated with screening for African American men (∼3 y), but the rate of overdiagnosis was higher among African American men. The authors suggested that annual screening for men aged 45-69 y is the optimal balance of benefits and harms for African American men, leading to a mortality reduction of 26%-29% while limiting overdiagnosis to 51-61 per 1000 men. If annual screening were applied without age limit, mortality reduction was increased to 29%-31% but overdiagnosis ballooned to 112-129 per 1000 men. | 1-4 | N/A |
| Preston 2019 (31) |
| The purpose of this study was to determine whether baseline PSA level during midlife predicts the risk of aggressive prostate cancer in African American men. Median PSA among control men was 0.72, 0.80, 0.94, and 1.03 ng/mL for the age groups 40-49 y, 50-54 y, 55-59 y, and 60-64 y, respectively; 90th percentile levels were 1.68, 1.85, 2.73, and 3.33 ng/mL. The authors found that PSA levels in midlife strongly predicted subsequent development of aggressive prostate cancer; 95% of men who developed prostate cancer and 97% of men who developed aggressive prostate cancer had a baseline PSA value above the age-specific median. In men with PSA levels greater than the median vs less than or equal to the median, the odds ratio for aggressive prostate cancer was 49.6 (95% CI = 10.8 to infinity) for men aged 40-54 y. PSA levels from 1 to 3 ng/mL were indicative of large increases in risk, with few prostate cancer cases occurring among men with levels <1 ng/mL. | 1-3 | 10 |
| Qiao 2022 (47) |
| The authors purported that there is an absence of information and research about screening practices specific to African American men, so they created a retrospective cohort through the VA. This was a retrospective analysis of screening practices of African American male veterans through the VA system aged 40-55 y diagnosed with prostate cancer between 2004 and 2017. The authors then calculated the percentage of annual PSA screening 5 y before diagnosis; 5.4% of patients received annual PSA screenings, 22.4% received no prior PSA screening, 36.5% had annual visits, and 10.2% had no annual visits. The correlation between primary care professional visits and PSA testing was 0.68 (P < .001). Patients without previous PSA testing had higher PSA values, higher frequency of Gleason score ≥8 tumors, and higher rates of metastatic disease. Men with ≥1 PSA screenings had 44% lower odds of having a PSA value >20 ng/mL, 22% lower odds of having a Gleason score ≥8 tumor, and 50% lower odds of having metastatic disease at diagnosis. Patients with prior PSA screening had lower cumulative incidence of prostate cancer–specific mortality at median follow-up. PSA screening improved prostate cancer outcomes for patients. | 1, 2 | 9 |
| Sherer 2022 (56) |
| This VA-based retrospective cohort studied 45 834 men and analyzed the association between PSA screening and risk of prostate cancer–specific mortality. The authors also analyzed screening practices leading up to diagnosis. The average age of the study population was 62.7 y, and 31% of patients were non-Hispanic Black. PSA screening rate was associated with lower risk of prostate cancer–specific mortality among non-Hispanic Black men (subdistribution hazard ratio = 0.56, 95% CI = 0.41 to 0.76, P = .001). Annual screening vs “some” screening was statistically significant in decreasing risk for the non-Hispanic Black population (subdistribution hazard ratio = 0.65, 95% CI = 0.46 to 0.92, P = .02) but not for the non-Hispanic White population. The authors found that annual PSA screening is important for reducing prostate cancer–specific mortality in the non-Hispanic Black community but not in the non-Hispanic White community, suggesting the need for more tailored guidelines for screening practices. | 1, 3 | 15 |
| Tang 2010 (57) |
| The purpose of this study was to learn whether baseline PSA can be used to stratify patients and predict risk of death from prostate cancer and death from all causes in the population targeted for PSA measurement. Multivariate findings included those men with a baseline PSA of 4.0-9.9 ng/mL and 10 ng/mL were found to have a 3.0-fold and 11.5-fold higher rate of death from prostate cancer, respectively, compared with men with a baseline PSA value <2.5 ng/mL. Having a baseline PSA value of 10 ng/mL predicted death from prostate cancer with 77% sensitivity and 78% specificity. Being African American and at advanced age at the time of baseline PSA measurement was associated with a higher rate of death from prostate cancer and death from all causes. | 1, 3 | 17 |
| Telesca 2008 (35) |
| The authors gathered information about the increase and decline in prostate cancer incidence following the adoption of PSA testing to estimate the lead time associated with PSA screening. They found that an average lead time of approximately 4.59 y for European Americans and 6.78 y for African Americans with a corresponding secular trend that was flattened after the introduction of PSA screening. The authors concluded that if PSA screening had not occurred, the incidence of prostate cancer would not have increased, but prostate patterns of care unrelated to PSA would have leveled off. | 1, 2, 4 | N/A |
| Tsodikov 2017 (46) |
| Tsodikov and colleagues calibrated 3 natural history models of prostate cancer to observed incidence data in SEER given a construction of national screening trends based on the National Health Interview Survey and SEER-Medicare data. Absolute risk of developing preclinical disease is 30%-43% among African American men (higher than ∼25% in all men). Among men with disease onset, risk of clinical diagnosis does not differ by race, but risk of metastatic disease before diagnosis was higher among African American men, 44%-75% higher than the general population. Assuming that screening should begin at 55 y of age generally, African American men reach risk threshold for relevant disease 3-9 y earlier than their counterparts from other races. | 1-4 | N/A |
| Whittemore 1995 (33) |
| The purpose of this study was to evaluate serum PSA levels and subsequent prostate cancer occurrence in a cohort of young African American and White men. Using cohort data from Kaiser Permanente Medical Care Plan of Northern California, the authors analyzed serial PSA concentrations in sera collected from 136 men (40 African American men and 96 White men) who were subsequently diagnosed with histologically confirmed prostate cancer and from 184 men (84 African American men and 100 White men) without subsequent diagnosis of prostate cancer. There were no statistically significant differences in the performance of the markers by race. High-risk prostate cancer cutoff was defined as if last PSA concentration exceeded 7.3 (4.0) ng/mL, regardless of the man’s age. | 1, 3 | 13 |
| Whittemore 2005 (32) |
| The purpose of this study was to examine the associations between PSA levels in young adulthood and subsequent prostate cancer risk using a nested case-control design. For the reported associations of baseline PSA levels in subgroups of matched case-control sets defined by race, age at risk for prostate cancer, and case diagnosis year, African American men who were younger than 65 y of age were 7.4 times more likely than the control group to have a PSA level ≥0.56 ng/mL. As it relates to screening recommendations for prostate cancer in men younger than 65 y of age, it may be best to monitor those with increased PSA levels and perform biopsy when levels start to increase consistently at a rate exceeding some critical value because the biopsy process is psychologically burdensome for some men. | 1, 3 | 17 |
Risk of bias summary score ranged from 7 to 21 and were not determined for modeling studies (see Supplementary Table 2, available online). CAP = Cluster Randomized Trial of PSA Testing for Prostate Cancer; CI = confidence interval; N/A = not applicable; PLCC = Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial; PSA = prostate-specific antigen; SEER = Surveillance, Epidemiology, and End Results program; VA = US Department of Veterans Affairs.
Summary of key questions regarding prostate cancer screening using PSA among African American men
| Question . | USPSTF guidelinea . | Literature guidance . | Future research needs . | Levels of evidence (20) . |
|---|---|---|---|---|
| 1. Should we screen African American men with PSA levels for prostate cancer? | The USPSTF guideline states that the decision to test PSA levels should be a shared decision between patients and their clinicians. African American men and men with a family history of prostate cancer are acknowledged to experience higher prostate cancer risk, but no guidance on clinical care is provided for these groups. | African American men should be screened for prostate cancer, using PSA to lower prostate cancer–specific mortality. In consideration of potential harms, PSA can be used in conjunction with other information to stratify prostate cancer risk, and magnetic resonance imaging can be incorporated before to biopsy. | Data that support how the use of PSA, alone or in combination with other markers, may help improve the benefit-risk trade-off of screening among African American men. | Level 3 |
| 2. When should screening for prostate cancer be initiated among African American men? | The USPSTF guideline states that although the decision to screen for prostate cancer should be made through shared decision making with a clinician, this discussion should not be initiated until the patient is 55 y of age. | African American men could consider initiation of prostate cancer screening at earlier ages (approximately 45-50 y) relative to men at average risk of prostate cancer. Family history of prostate cancer and inherited genetic risk may also be potential considerations in initiating prostate cancer risk assessment among African American men. | Data that support the initial age at which the benefits and harms are in equipoise for specific risk groups, including those defined by genetics, family history, age, and other factors. | Level 3 |
| 3. How often should African American men be screened for prostate cancer? | The USPSTF guideline states that men who have made the decision to screen should do so “periodically.” | There is a lack of evidence regarding the optimal screening interval among African American men. The cadence of screening may be based on a midlife PSA value to direct whether and how often future PSA measures will be needed. | Data that support the value of midlife PSA testing in predicting future rises in PSA and lethal prostate cancer diagnosis by age and risk level. | Level 3 |
| 4. When should screening for prostate cancer be stopped among African American men? | The USPSTF guideline recommends against conducting prostate cancer screening using PSA among men aged 70 y or older. | There is a paucity of data pertaining to screening cessation. PSA measurement after age 70 or when patient life expectancy is low may increase the risk of overdiagnosis among African American men. | Data support the latest age at which the benefits and harms are in equipoise for specific risk groups, including those defined by genetics, family history, age, and other factors. | Level 3 |
| 5. Which modalities should be used for prostate cancer screening among African American men? | The USPSTF guideline recommends prostate cancer screening using PSA only following shared decision making. Digital rectal examination is not recommended for use in prostate cancer screening. No other modalities for screening are considered in the recommendation. | There are limited data to define the relative value of PSA testing vs other screening modalities in African American men. | Direct comparison of test characteristics for various forms of PSA, 4Kscore, and other tools to determine whether the tests perform similarly in African American men as in other groups. | Level 3 |
| Question . | USPSTF guidelinea . | Literature guidance . | Future research needs . | Levels of evidence (20) . |
|---|---|---|---|---|
| 1. Should we screen African American men with PSA levels for prostate cancer? | The USPSTF guideline states that the decision to test PSA levels should be a shared decision between patients and their clinicians. African American men and men with a family history of prostate cancer are acknowledged to experience higher prostate cancer risk, but no guidance on clinical care is provided for these groups. | African American men should be screened for prostate cancer, using PSA to lower prostate cancer–specific mortality. In consideration of potential harms, PSA can be used in conjunction with other information to stratify prostate cancer risk, and magnetic resonance imaging can be incorporated before to biopsy. | Data that support how the use of PSA, alone or in combination with other markers, may help improve the benefit-risk trade-off of screening among African American men. | Level 3 |
| 2. When should screening for prostate cancer be initiated among African American men? | The USPSTF guideline states that although the decision to screen for prostate cancer should be made through shared decision making with a clinician, this discussion should not be initiated until the patient is 55 y of age. | African American men could consider initiation of prostate cancer screening at earlier ages (approximately 45-50 y) relative to men at average risk of prostate cancer. Family history of prostate cancer and inherited genetic risk may also be potential considerations in initiating prostate cancer risk assessment among African American men. | Data that support the initial age at which the benefits and harms are in equipoise for specific risk groups, including those defined by genetics, family history, age, and other factors. | Level 3 |
| 3. How often should African American men be screened for prostate cancer? | The USPSTF guideline states that men who have made the decision to screen should do so “periodically.” | There is a lack of evidence regarding the optimal screening interval among African American men. The cadence of screening may be based on a midlife PSA value to direct whether and how often future PSA measures will be needed. | Data that support the value of midlife PSA testing in predicting future rises in PSA and lethal prostate cancer diagnosis by age and risk level. | Level 3 |
| 4. When should screening for prostate cancer be stopped among African American men? | The USPSTF guideline recommends against conducting prostate cancer screening using PSA among men aged 70 y or older. | There is a paucity of data pertaining to screening cessation. PSA measurement after age 70 or when patient life expectancy is low may increase the risk of overdiagnosis among African American men. | Data support the latest age at which the benefits and harms are in equipoise for specific risk groups, including those defined by genetics, family history, age, and other factors. | Level 3 |
| 5. Which modalities should be used for prostate cancer screening among African American men? | The USPSTF guideline recommends prostate cancer screening using PSA only following shared decision making. Digital rectal examination is not recommended for use in prostate cancer screening. No other modalities for screening are considered in the recommendation. | There are limited data to define the relative value of PSA testing vs other screening modalities in African American men. | Direct comparison of test characteristics for various forms of PSA, 4Kscore, and other tools to determine whether the tests perform similarly in African American men as in other groups. | Level 3 |
Note that USPSTF guidelines do not themselves constitute evidence but are presented here to provide context in which our evidence base can be used to develop future guidelines. PSA = prostate-specific antigen; USPSTF = United States Preventive Services Task Force.
Summary of key questions regarding prostate cancer screening using PSA among African American men
| Question . | USPSTF guidelinea . | Literature guidance . | Future research needs . | Levels of evidence (20) . |
|---|---|---|---|---|
| 1. Should we screen African American men with PSA levels for prostate cancer? | The USPSTF guideline states that the decision to test PSA levels should be a shared decision between patients and their clinicians. African American men and men with a family history of prostate cancer are acknowledged to experience higher prostate cancer risk, but no guidance on clinical care is provided for these groups. | African American men should be screened for prostate cancer, using PSA to lower prostate cancer–specific mortality. In consideration of potential harms, PSA can be used in conjunction with other information to stratify prostate cancer risk, and magnetic resonance imaging can be incorporated before to biopsy. | Data that support how the use of PSA, alone or in combination with other markers, may help improve the benefit-risk trade-off of screening among African American men. | Level 3 |
| 2. When should screening for prostate cancer be initiated among African American men? | The USPSTF guideline states that although the decision to screen for prostate cancer should be made through shared decision making with a clinician, this discussion should not be initiated until the patient is 55 y of age. | African American men could consider initiation of prostate cancer screening at earlier ages (approximately 45-50 y) relative to men at average risk of prostate cancer. Family history of prostate cancer and inherited genetic risk may also be potential considerations in initiating prostate cancer risk assessment among African American men. | Data that support the initial age at which the benefits and harms are in equipoise for specific risk groups, including those defined by genetics, family history, age, and other factors. | Level 3 |
| 3. How often should African American men be screened for prostate cancer? | The USPSTF guideline states that men who have made the decision to screen should do so “periodically.” | There is a lack of evidence regarding the optimal screening interval among African American men. The cadence of screening may be based on a midlife PSA value to direct whether and how often future PSA measures will be needed. | Data that support the value of midlife PSA testing in predicting future rises in PSA and lethal prostate cancer diagnosis by age and risk level. | Level 3 |
| 4. When should screening for prostate cancer be stopped among African American men? | The USPSTF guideline recommends against conducting prostate cancer screening using PSA among men aged 70 y or older. | There is a paucity of data pertaining to screening cessation. PSA measurement after age 70 or when patient life expectancy is low may increase the risk of overdiagnosis among African American men. | Data support the latest age at which the benefits and harms are in equipoise for specific risk groups, including those defined by genetics, family history, age, and other factors. | Level 3 |
| 5. Which modalities should be used for prostate cancer screening among African American men? | The USPSTF guideline recommends prostate cancer screening using PSA only following shared decision making. Digital rectal examination is not recommended for use in prostate cancer screening. No other modalities for screening are considered in the recommendation. | There are limited data to define the relative value of PSA testing vs other screening modalities in African American men. | Direct comparison of test characteristics for various forms of PSA, 4Kscore, and other tools to determine whether the tests perform similarly in African American men as in other groups. | Level 3 |
| Question . | USPSTF guidelinea . | Literature guidance . | Future research needs . | Levels of evidence (20) . |
|---|---|---|---|---|
| 1. Should we screen African American men with PSA levels for prostate cancer? | The USPSTF guideline states that the decision to test PSA levels should be a shared decision between patients and their clinicians. African American men and men with a family history of prostate cancer are acknowledged to experience higher prostate cancer risk, but no guidance on clinical care is provided for these groups. | African American men should be screened for prostate cancer, using PSA to lower prostate cancer–specific mortality. In consideration of potential harms, PSA can be used in conjunction with other information to stratify prostate cancer risk, and magnetic resonance imaging can be incorporated before to biopsy. | Data that support how the use of PSA, alone or in combination with other markers, may help improve the benefit-risk trade-off of screening among African American men. | Level 3 |
| 2. When should screening for prostate cancer be initiated among African American men? | The USPSTF guideline states that although the decision to screen for prostate cancer should be made through shared decision making with a clinician, this discussion should not be initiated until the patient is 55 y of age. | African American men could consider initiation of prostate cancer screening at earlier ages (approximately 45-50 y) relative to men at average risk of prostate cancer. Family history of prostate cancer and inherited genetic risk may also be potential considerations in initiating prostate cancer risk assessment among African American men. | Data that support the initial age at which the benefits and harms are in equipoise for specific risk groups, including those defined by genetics, family history, age, and other factors. | Level 3 |
| 3. How often should African American men be screened for prostate cancer? | The USPSTF guideline states that men who have made the decision to screen should do so “periodically.” | There is a lack of evidence regarding the optimal screening interval among African American men. The cadence of screening may be based on a midlife PSA value to direct whether and how often future PSA measures will be needed. | Data that support the value of midlife PSA testing in predicting future rises in PSA and lethal prostate cancer diagnosis by age and risk level. | Level 3 |
| 4. When should screening for prostate cancer be stopped among African American men? | The USPSTF guideline recommends against conducting prostate cancer screening using PSA among men aged 70 y or older. | There is a paucity of data pertaining to screening cessation. PSA measurement after age 70 or when patient life expectancy is low may increase the risk of overdiagnosis among African American men. | Data support the latest age at which the benefits and harms are in equipoise for specific risk groups, including those defined by genetics, family history, age, and other factors. | Level 3 |
| 5. Which modalities should be used for prostate cancer screening among African American men? | The USPSTF guideline recommends prostate cancer screening using PSA only following shared decision making. Digital rectal examination is not recommended for use in prostate cancer screening. No other modalities for screening are considered in the recommendation. | There are limited data to define the relative value of PSA testing vs other screening modalities in African American men. | Direct comparison of test characteristics for various forms of PSA, 4Kscore, and other tools to determine whether the tests perform similarly in African American men as in other groups. | Level 3 |
Note that USPSTF guidelines do not themselves constitute evidence but are presented here to provide context in which our evidence base can be used to develop future guidelines. PSA = prostate-specific antigen; USPSTF = United States Preventive Services Task Force.
Question 1: Should we screen African American men with PSA findings for prostate cancer?
Recommendations and evidence for the general population
The USPSTF cites 3 large RCTs of “fair quality” as providing sufficient evidence of mortality benefit at the individual level—the PLCO, ERSPC, and Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP) trials—considering the most recent trial reports with increased follow-up time (13). In the most recent results from the ERSPC, men in the PSA screening arm experienced 1.8 fewer deaths from prostate cancer per 1000 men screened, and the magnitude of the absolute effect of screening on prostate cancer–specific mortality increased with duration of follow-up (16). Earlier reports from the ERSPC showed that PSA screening significantly reduced risk of developing metastatic prostate cancer (21). The 16-year follow-up for PLCO showed no statistically significant reduction in prostate cancer–specific mortality in the intervention vs usual care arms (14). Modeling studies have demonstrated that after reconciling differences in the design, implementation, and setting of the PLCO and ERSPC trials, estimates of mean lead time were similar in both trials, and both trials provided compatible evidence that prostate cancer screening reduces prostate cancer mortality (22). The CAP trial was a single-invitation PSA test that at the 10-year follow-up did not demonstrate a significant difference in prostate cancer mortality but was limited by nonadherence, with only 34% of men in the intervention arm undergoing PSA testing (23). In all 3 trials, potential harms were discussed. Cumulative risks of having a false-positive result with repeat PSA-based screening were 10.4% in the PLCO trial and 17.8% in the ERSPC trial (24,25). In the PLCO trial, 2.0% of participants who underwent biopsy experienced complications, such as infection, bleeding, or difficulty urinating (26). The long-term absolute benefits and harms of screening as performed in these trials remain uncertain. As a result, the USPSTF recommends that the decision to use PSA screening to detect prostate cancer in men aged 55 to 69 years should involve a discussion between patient and clinician where possible benefits and harms are explored at an individual level (13).
Evidence for African American men
There is a lack of evidence for African American men from randomized screening trials that PSA-based screening reduces prostate cancer mortality. The literature, however, provides some support for screening African American men for prostate cancer using PSA. Serum PSA levels predict the presence of prostate cancer among African American men (27-33). The harms associated with routine PSA-based screening include an increase in the number of overdiagnoses, overtreatment of indolent disease, and risks associated with biopsy. Miller et al. (34) reported that the risk of a false-positive PSA test was higher among African American men (14.5%) than European American men (12.4%) in the PLCO trial. Telesca and colleagues (35) estimated that the lead time for PSA-based screening is 6.8 years for African American men and 4.6 years for European American men, using a modeling approach that incorporated screening and incidence data from the National Health Interview Survey and Surveillance, Epidemiology, and End Results program, respectively. Correspondingly, estimates of the proportion of prostate tumors that are overdiagnosed from that study are 34% among African American men and 22% among European American men (35). Weighing the mortality benefits associated with prostate cancer screening (based on changes in population prostate cancer mortality rates since 1986) against the risk of overdiagnosis and overtreatment, Basourakos and colleagues (36) estimated that the number needed to diagnose and the number needed to treat to prevent 1 prostate cancer death were 8 to 12 and 5 to 9, respectively, among African American men, depending on modeling approach. These numbers were lower than corresponding estimates of 11 to 14 (number needed to diagnose) and 7 to 11 (number needed to treat) in the general population (36). These findings imply a more favorable benefits to harms ratio for African American men and that mortality benefits associated with prostate cancer screening accrue with longer follow-up.
Question 1 conclusion
African American men who elect to undergo screening for prostate cancer should be offered a PSA test. The literature identified in our search suggested that the use of PSA information, combined with other information, could be used to stratify risk. Our literature search, however, did not identify sufficient data from African American men to allow us to make this inference with the level of evidence some groups (eg, USPSTF) require. Thus, additional studies are needed to evaluate how the use of PSA information, combined with other risk factors, imaging, or biomarkers, may help improve the benefit-risk trade-off of screening among African American men.
Question 2: When should screening for prostate cancer be initiated among African American men?
Recommendations and evidence for the general population
The age of initiation of prostate cancer screening or shared decision making regarding prostate cancer screening in current screening recommendations is generally 50 or 55 years for men at average risk (13). This age largely reflects the eligibility criteria in the large, randomized screening trials (15,23,37). According to the USPSTF, there is insufficient evidence to recommend whether the possible benefits of PSA screening in men younger than 55 years of age (or of a baseline PSA test performed at a younger age) would outweigh the possible harms (13). In contrast, the American Urological Association (AUA) concluded that there is sufficient evidence to support baseline screening for men aged 45 to 50 years based on observational evidence for its ability to predict clinically significant prostate cancer later in life (38). Conversely, the Centers for Medicare & Medicaid Services begins coverage of an annual PSA screening test at age 50 years (39), citing the American Cancer Society’s (ACS’s) recommendation that men at average risk begin counseling for shared decision making at 50 years of age (12). Results from the 22-year follow-up of the Göteburg Randomized Population-Based Prostate Cancer Screening Trial showed an elevated risk of being diagnosed with advanced prostate cancer if initial screening was deferred to 60 years of age, though this finding may be attributable to receiving fewer years of screening (40).
From autopsy studies of prostate cancer prevalence, it has been reported that men of African descent have a higher prevalence of prostate cancer than men of either European or Asian descent (41,42). Prostate cancer prevalence in men in their 40s was estimated to be 6.3%, 15.0%, and 24.7% in men of Asian, European, and African descent, respectively. Although not reported, the majority of these tumors were likely indolent in nature because they had not been detected clinically. For men in their 50s, these prevalence rates were 17.7%, 33.3%, and 56.7% by race, respectively. These data suggest first that the prevalence of prostate cancer is higher in African American men at of ages, but these data also indicate that latent (indolent) prostate cancer is common and that the majority of tumors may not need to be detected because risk of overdiagnosis increases with age (43-45).
Evidence for African American men
When examining the evidence specific to African American men, there is moderate support in the literature for initiating PSA screening in African American men in their 40s to improve outcomes and decrease all-cause mortality (27-29,31). Natural history models suggest that the age of preclinical prostate cancer onset is 3 to 9 years earlier among African American men than in the general US population, suggesting that the diagnostic yield would be similar if African American men started screening at earlier ages (46). These models estimate that the frequency of overdiagnosis is lower for men at younger ages (14% at ages 50-54 years for African American men) than at later ages (47% at ages 80-84 years for African American men), implying that there may be fewer harms associated with prostate cancer screening for men in an earlier age group (35). In a US Department of Veterans Affairs (VA) cohort, Qiao and colleagues (47) observed that history of PSA screening was associated with less aggressive tumor characteristics and lower prostate cancer–specific mortality among African American men aged 40 to 55 years diagnosed with prostate cancer. Nyame et al. (48) estimated that initiating annual screening of African American men at 45 years of age and stopping at 69 years of age would lead to a greater reduction in mortality (26%-29%) while maintaining a lower rate of overdiagnosis compared with historical screening practices.
Question 2 conclusion
Although there is insufficient data to determine the optimal age for screening initiation, the observation of earlier prostate cancer diagnosis in African American men and lower risk of overdiagnosis at younger ages suggests that if electing to undergo screening, African American men should initiate screening at an earlier age than men in other racial groups (eg, at approximately 45 years of age). There is a need, however, for more refined estimates of the optimal timing of screening initiation that considers family history, including age at prostate cancer diagnosis in relatives, inherited genetic alterations, or other factors and how these potential benefits weigh against the harms of early detection of indolent disease.
Question 3: How often should African American men be screened for prostate cancer?
Recommendations and evidence for the general population
The USPSTF does not currently provide a recommendation regarding PSA screening intervals, largely because of variation in intervals in the 3 RCTs (49). Participants in the intervention arm of the PLCO were assigned to receive annual PSA tests (50), while in the ERSPC trial the interval was site dependent, with 4-year intervals used at most sites (with the exception of Sweden, in which biennial screening was performed) (37). The CAP study did not have a screening interval because it was a 1-time invitation to test (23). As a result, instead of providing an interval, the USPSTF states this decision is an inherent aspect of shared decision making and places the onus on the clinician to reassess and provide further counsel (13). The ACS recommends biennial screening for men with a PSA level less than 2.5 ng/mL and annual screening for men with a PSA level of more than 2.5 ng/mL, citing evidence from simulation studies that extending screening intervals can reduce the number of tests and biopsies while maintaining the vast majority of the mortality benefit and evidence from the PLCO and observational studies that among men with low PSA levels (<1.0 ng/mL), conversion to a PSA level above 4.0 ng/mL is highly unlikely within 2 years (12,18,51-53). The AUA states that there is sufficient evidence to support that clinicians should offer PSA screening every 2 to 4 years but also tailor the interval until the next test to the patient (38). Modeling approaches show that extending screening intervals for men with low PSA levels can reduce the likelihood of a false-positive test and the number of tests overall while preserving most of the mortality benefit of the test (54,55).
Evidence for African American men
The evidence for African American men indicates a lack of consensus regarding the optimal prostate cancer screening cadence. There is limited information in African American men that can guide practice, although it is likely that a persistently low PSA value should indicate a lower requirement for frequent testing and the potential to stop screening altogether (31). African American men, however, may benefit from more frequent screening, given the higher incidence and faster progression to metastatic prostate cancer in this population (46). Tsodikov and colleagues (46) estimated using natural history that African American men had a higher risk of being diagnosed with metastatic disease given biological onset of a tumor relative to men of all races (9%-13% vs 6%-9%), and the mean time from onset to metastatic clinical diagnosis may be faster among African American men (12-16 years vs 13-21 years). Using data from the VA, Sherer et al. (56) found that annual screening in the 5 years before diagnosis relative to some screening was associated with reduced prostate cancer mortality among African American men aged 55 to 69 years, with no association observed among non-Hispanic White men. Based on modeling data, Nyame et al. (48) support annual screening of African American men between the ages of 45 and 69 years, although the estimated mortality benefit associated with increasing screening frequency relative to historical averages is in part offset by increased risk of overdiagnosis.
A growing body of literature suggests that the frequency of screening be based on a midlife PSA value, taken at a time point before conditions that elevate PSA, such as benign prostatic hyperplasia, are common (28,31). Midlife PSA has been shown to be a reliable, independent predictor of prostate cancer mortality later in life (28,31-33,57,58). Additionally, a baseline or midlife PSA measurement can be used to personalize subsequent screening practices. For example, Preston et al. (31) found that with up to 12 years of follow-up, African American men who had midlife PSA levels in the upper age-specific decile had a 79-fold higher risk of being diagnosed with aggressive prostate cancer in the future relative to men below the age-specific median. Differences in study designs, populations, time periods, and outcome definitions complicate comparison of the findings of Preston et al. against other studies of baseline PSA conducted in predominantly European American populations, but Preston and colleagues assert that risk stratification of aggressive prostate cancer is at least as good among African American men as European American men and that African American men would benefit from screening strategies based on midlife PSA, as well (31,59,60). Using data from the predominantly European American participants of the PLCO trial, Landy et al. (58) supported a 5-year screening interval if a patient’s baseline PSA value (measured at trial enrollment, aged 55-74 years) was found to be 1 ng/mL or less. Landy et al. (58) also reported that African American men did not have higher prostate cancer incidence in the initial 5-year period following baseline PSA but had a statistically elevated risk of total and aggressive prostate cancer risk over a 10-year period. Preston et al. (31) broadly recommended that African American men with a baseline PSA level above their age-specific median receive more frequent screening. This method would not change the standard of care for most men but would target individuals at demonstrably higher risk. It is noted, however, that as African American men are at higher risk overall, the benefits to harms ratio for this population must be further evaluated (46).
Question 3 conclusion
Evidence regarding optimal screening intervals is weak among African American men. The cadence of screening can likely be optimized by adapting screening intervals based on current PSA levels, starting with the use of a midlife PSA value to guide the initial interval.
Question 4: When should screening for prostate cancer be stopped among African American men?
Recommendations and evidence for the general population
Current screening guidelines broadly agree that there is little evidence of a benefit to prostate cancer screening among men 70 years of age or older; in fact, there are increasing concerns about the impact of overdiagnosis and overtreatment among men in this age group. The PLCO trial enrolled individuals up to 74 years of age, and the prespecified core age group of the ESRPC and CAP trials was 69 years (13). Although men older than 70 years of age were included in the ERSPC trial, the trial investigators found no effect of screening on prostate cancer mortality among men 70 years of age or older at randomization (37). The most recent results from the Göteburg trial found that among men who participated in the screening program, 15% (213/1380) of prostate cancer diagnoses occurred more than 2 years after the age of screening cessation (median = 69 years) (40). Of those cases detected 2 or more years after the screening period (median age at diagnosis = 76 years), 13% were low risk, 41% were intermediate risk, 27% were high risk, and 13% were advanced prostate cancer; ultimately, 12% of these men died from prostate cancer, suggesting that there may be benefits to extending screening later in life (40). Because of the USPSTF guidelines’ heavy reliance on the results of these 3 RCTs, the small amount of evidence does not demonstrate benefits outweighing possible harms, which include observed higher rates of overdiagnosis, higher rates of false positives, and lower likelihood of reaching time to realize benefit (61). Rather than recommending an age-based cessation of treatment, the ACS considers overall health status in its recommendation against screening in men with a life expectancy less than 10 years (12). The ACS argues that at age 75, 50% of the population has a life expectancy of 10 years or longer; therefore, cessation of screening should not be age based because these men could realize the potential benefits of screening (12,62). The AUA states that the age to stop screening can be flexible and rather should be focused on the individual’s health and prior PSA levels (38). The AUA also notes that if a patient is older than 75 years of age and has a PSA level below 3 ng/mL, screening can be delayed or even stopped because of the extremely low likelihood of developing clinically significant disease (38). Simulation studies show that comorbidity status has a strong influence on the likelihood of overdiagnosis and should be considered in decisions regarding screening cessation (45,63).
Evidence for African American men
Natural history models suggest that mean times from disease onset to clinical diagnosis or to metastatic clinical diagnosis are 10 to 18 years and 12 to 16 years, respectively, for African American men (46). The model of Telesca et al. (35) suggested that the frequency of overdiagnosis for African American men aged 70 to 74 years (34%) exceeded the frequency for White men within this age group (20%). Landy et al. (58) suggested that men aged 65 years or older with PSA values of 0.5 ng/mL or lower could consider stopping screening, finding in the PLCO that no men 65 years of age or older with PSA values of 0.5 ng/mL or less had died from prostate cancer within 15 years and that 10-year cumulative incidence of aggressive prostate cancer was low (0.25%, 95% confidence interval = 0.00% to 0.53%) in this group. This recommendation, however, was limited by the predominantly European American population of the PLCO and is not specific to African American men (58). Nyame et al. (48) found in a modeling study that cessation of screening at age 70 rather than 84 may have a profound effect on limiting overdiagnosis. They also found that when stopping screening at 84 vs 70 years of age, the overdiagnosis rate shifted from 112 to 129 per 1000 men to 51 to 61 per 1000 men (48). The race-specific incidence rate of distant-stage disease among African American men aged 70 to 74 years was 94.5 per 100 000 (compared with that of European American men at 44.8 per 100 000), and the race-specific mortality rate for African American men 75 to 80 years of age was 1113.6 per 100 000 (compared with European American men at 530.6 per 100 000). These rates suggest that an appropriate stopping age for PSA screening should be around 70 years of age.
Question 4 conclusion
Evidence for the optimal timing of screening cessation among African American men is weak, but data support increased overdiagnosis among African American men with PSA measurement after age 70. Further studies are needed to inform how the incorporation of information about risk factors may help inform the optimal stopping age in a way that balances the benefits of detecting treatable, potentially fatal disease with the risks of overtreatment.
Question 5: Which modalities should be used for prostate cancer screening among African American men?
Recommendations and evidence for the general population
The PSA test is the sole method of screening for prostate cancer in the USPSTF, ACS, and AUA guidelines. No guidelines support the use of digital rectal examination (DRE) as part of routine prostate cancer screening. Numerous biomarkers have been developed to complement the use of PSA for early detection of clinically significant prostate cancer, including percent free PSA, the Prostate Health Index, MyProstateScore, the 4Kscore test, Select mdx, the ExoDx Prostate Test (64,65). Among these, the 4Kscore, a blood-based biomarker test specifically designed to diagnose clinically significant prostate cancer over indolent cancer, has been accepted in the European Union as a method to decrease overdiagnosis and unnecessary biopsies; it is recommended after an elevated PSA level but before a biopsy (66). In the United States, however, the 4Kscore is not covered by Medicare and Medicaid, which cite inadequate validation in its coverage determination (67). Risk-stratified prostate cancer screening may also be informed through incorporation of polygenic risk scores. Contemporary polygenic risk scores demonstrate strong prediction of clinically significant prostate cancer in diverse patient populations (68,69). The use of multiparametric magnetic resonance imaging (MRI) for risk stratification before biopsy is a newer technology endorsed by the AUA and National Comprehensive Cancer Network (70).
Evidence for African American men
Measurement of total PSA is currently the most frequently used modality for prostate cancer screening. No evidence has been identified in the literature for other, novel prostate cancer screening biomarkers, apart from the 4Kscore. In an analysis conducted among 946 men (100 African American) in the intervention arm of the PLCO trial, Kim et al. (71) showed that the 4Kscore has similar discrimination of high-grade prostate cancer in African American men as in men of other races. The area under the curve for detection of high-grade prostate cancer in the total population was higher using the 4Kscore (0.79) vs total PSA plus DRE (0.71; P < .01). Model discrimination for the 4Kscore and total PSA plus DRE did not significantly differ between African American men and men of other racial groups, while no statistical comparison was performed as to whether 4Kscore had superior discrimination relative to total PSA plus DRE specifically among African American men (71). Further evidence is needed regarding the efficacy, sensitivity, and specificity of the 4Kscore and other screening biomarkers (such as percent free PSA, Prostate Health Index, and MyProstateScore) among African American men.
Use of multiparametric MRI and fusion biopsy has increased in the past decade as useful tools to increase the accuracy of biopsies while also avoiding unnecessary biopsies. Use of multiparametric MRI as a triaging tool after an elevated PSA level is also characterized by disparity (72,73). African American men are less likely than other racial/ethnic groups to receive a prostate MRI, with poorer access that may arise from residential segregation and socioeconomic disadvantage as well as dual eligibility for Medicare and Medicaid (74). Recent reports that biparametric MRI may have a similar diagnostic yield as multiparametric MRI could lead to increased access to MRI-targeted biopsy because biparametric MRI has reduced codes relative to multiparametric MRI because of the omission of costs related to contrast agents and additional MRI sequences as well as shorter imaging/labor time (75,76). Use of urine-based biomarker tests may also be more cost-effective for men with intermediate PSA levels (4-10 ng/mL) relative to multiparametric MRI (77). Incorporating new technologies such as multiparametric MRI into guidelines will necessitate plans to ensure equitable access for African American men who may experience greater barriers related to medical contact and expense.
Question 5 conclusion
Data to define the relative value of PSA vs other modalities for prostate cancer screening among African American men are limited. Equitable access to screening and follow-up modalities must be a major consideration of health systems that implement prostate cancer screening to avoid exacerbating existing racial disparities in this disease.
Discussion
Despite the higher incidence and mortality of prostate cancer among African American men relative to other racial groups in the United States, there is a paucity of empirical evidence regarding the benefits and harms of PSA-based prostate cancer screening in this population. Our review identified few studies that provided evidence for key questions concerning prostate cancer screening among African American men. Moreover, this evidence predominantly consisted of observational studies—often retrospective and of limited sample size—and modeling studies, with little to no evidence available from large, randomized studies. Consequently, current recommendations for African American men must be developed based on our understanding of the general mechanism underlying PSA benefit, the likelihood that this mechanism also applies to African American men, and calculation of how the now well-quantified increase in disease risk in African American men may translate into benefit and benefit-harm ratios in this population. The available evidence suggests that African American men should be screened for prostate cancer, and consideration should be given to initiating screening at younger ages (45-50 years) and perhaps at more frequent intervals relative to men of other racial groups in the United States. Screening intervals may be optimized through use of a baseline PSA measurement in midlife. There was no evidence that African American men would benefit from screening beyond age 75; indeed, African American men may be more likely to be harmed by overdiagnosis at older ages. Evidence for the effectiveness of alternative screening modalities among African American men is lacking. In total, the evidence base is limited by the lack of large, randomized studies to inform screening recommendations in this population.
In the United States, prostate cancer screening rates declined in the wake of the 2012 USPSTF recommendation against routine PSA-based screening, though rates may be stabilizing following the 2018 updated recommendation (78-81). A larger decline in screening has occurred among African American men following the 2012 recommendation, particularly among men age 40 to 54 (82). The deferral of health care because of the COVID-19 pandemic has likely also led to reduced prostate cancer screening in recent years (83). Alongside overall decreases in population screening, there have been shifts to later stage at diagnosis and increased metastatic disease (78-80,82). Additionally, although prostate cancer mortality rates had been declining before 2012, these rates plateaued from 2014 to 2019 (84). Thus, there is a pressing need to intervene to stem these alarming trends suggesting that the burden of prostate cancer in the United States may once again be growing, particularly among African American men. Development and implementation of prostate cancer screening guidelines informed by rigorous evidence and tailored to African American men may be a potential tool to mitigate the excess impact of prostate cancer that African American men experience.
The notion of tailoring prostate cancer screening guidelines by self-identified race alone may be met with skepticism. Although race and ethnicity are frequently reported to be risk factors for prostate cancer, race itself is a social and power construct linked to many factors that act on prostate cancer risk and progression, be they social, behavioral, environmental, or biological. Alternative metrics for self-identified race and ethnicity, such as genomic ancestry, could be considered, but the use of such alternatives in assessing prostate cancer screening use have not been studied, nor is it clear that these metrics could be implemented in the general population.
There are numerous examples of how race-based medicine has led to harms and worse standards of clinical care for marginalized racial populations (85), but a race-conscious approach may be beneficial in prostate cancer, taking into consideration structural and systemic factors that affect disparate outcomes for African American men. Disparities in prostate cancer survival disappear in settings with equal access to health care, such as RCTs and the VA health-care system, suggesting that racial differences in prostate cancer mortality following diagnosis in general population–based cohorts may arise from racial inequities in health-care access, reflecting in part structural racism and discrimination within the health-care system (86,87). Variation in prostate cancer incidence across racial groups likely reflects a combination of inherited genetic risk, behavioral and environmental factors, and social determinants that are the consequences of systemic racism (88). Similarly, differences in prostate cancer survival in population-based cohorts by race may arise from racial inequities, and hypothesized mechanisms for these effects could include immunologic, inflammatory, epigenetic, metabolic, and other pathways. At 57%, genetic heritability of prostate cancer is among the highest across cancer sites (89). Few risk factors have been identified for prostate cancer, and the magnitude of the potential effect of such factors likely cannot explain differences in prostate cancer incidence by race (90,91). Press and colleagues (92) reported that neighborhood socioeconomic status was the most influential factor contributing to racial disparities in prostate cancer risk profiles. Although the precise causal mechanisms underlying differences in prostate cancer risk by race require further study, it is evident that African American men face higher risk of prostate cancer. Cancer screening recommendations routinely target populations that experience higher cancer risk, including defining high-risk populations on the basis of age, sex, and behaviors such as tobacco use. The evidence suggests that the trade-offs and harms linked to prostate cancer screening may be different for African American men than for men of other racial groups. Thus, there is a need to determine whether distinct prostate cancer screening guidelines are warranted for African American men and, if so, what the recommended screening regimen should be.
We postulate that PSA and other screening tools have no intrinsic benefit or harm; the benefit and harm stem from the interpretation and use of the information that these modalities provide. Prostate cancer is often indolent in nature, although the aggressive forms of prostate cancer are more common in African American men (93). Thus, an integral component of using screening properly is to balance underdetection with overdiagnosis and overtreatment. This trade-off can be better optimized in screening regimens as well as in the clinical management of an abnormal screening result or following a diagnosis of low-risk disease. Incorporation of MRI or additional blood or urinary markers to total serum PSA (such as serum-free PSA, 4Kscore, prostate cancer antigen 3, or TMPRSS2:ERG) may improve the specificity for detection of clinically significant prostate cancer (94). The screening regimens themselves can be optimized to avoid low-value testing through risk stratification based on midlife PSA or polygenic risk scores (2,95,96). Multiparametric MRI and biparametric MRI have become increasingly valuable tools for guiding the use of biopsy after an elevated PSA result. The reference values for PSA may also merit further evaluation because healthy African American men may have higher PSA levels relative to men of other races or ethnicities. These studies, however, may be limited by the higher prevalence of latent prostate cancer among African American men (97,98). Incorporation of any of these elements into screening approaches requires careful consideration of the implementation approach to ensure that risk-stratified screening reaches all populations, allowing individuals to retain autonomy of decision making and the confidentiality of their genetics and ensuring that “low-risk” individuals do not receive or perceive that they receive inferior care (99). Risk models (eg, Stockholm 3 [STHLM3]) or the presence of germline pathogenic mutations associated with elevated prostate cancer risk have also been proposed to stratify men into risk categories and thus personalize screening based on individual risk levels. Although many of these tools and strategies hold promise for improved prostate cancer screening, there is limited to no evidence that would specifically guide their use in African American men.
Following a prostate cancer diagnosis, overtreatment of otherwise indolent tumors that pose minimal risk of significant morbidity or mortality can be minimized through increased use of active surveillance. Use of active surveillance in the male African American population has been questioned because of some evidence that African American men have a higher frequency of biochemical reoccurrence after treatment and a higher rate of conversion to definitive treatment (100,101). The majority of studies, however, indicate that the safety profile of active surveillance is similar for African American men and men of other racial groups (102-105). Notably, there are marked differences in the intensity of surveillance between African American men and men of other racial groups. In an analysis of 2238 male (115 African American men [5%]) Medicare beneficiaries diagnosed with localized Gleason 3 + 3 or 3 + 4 prostate cancer in 2010-2015, more than half of men participating in active surveillance did not have a surveillance biopsy within 2 years of diagnosis (106). African American men on active surveillance were also found to be significantly less likely to undergo PSA tests, MRI scans, and surveillance biopsies than their counterparts from other racial groups (106).
There is a clear need for evidence to guide whether prostate cancer screening recommendations should differ for high-risk populations, including African American men. It is highly unlikely that further large RCTs on the scale of the PLCO or ERSPC trials will be performed to generate the evidence base needed to better inform prostate cancer screening recommendations for these populations. Accordingly, such evidence regarding the effectiveness of prostate cancer screening and specific screening regimens tailored to high-risk populations will need to be generated predominantly through simulation studies or in observational studies conducted in large health-care databases. Using existing health-care databases will allow for the examination of more screening regimens with regard to screening initiation, frequency, and cessation than could feasibly be examined in randomized experiments, with the additional benefit of expedited findings because follow-up for cancer incidence and mortality has already occurred. Inference of causal effects in observational studies is, of course, complicated by nonrandom treatment allocation, leaving effect estimates generated through these studies prone to residual confounding. Although residual confounding may remain a concern, however, study design frameworks, such as target trial emulation, can help mitigate other forms of bias that commonly occur in observational studies, such as selection bias and immortal time bias (107,108).
Despite the higher prostate cancer incidence and mortality among African American men, our review confirms that there is limited evidence to guide prostate cancer screening for this population. Given the dearth of modifiable risk factors for this disease, optimization of screening represents 1 of the better tools available for prostate cancer control. Despite the limited evidence available to guide screening in African American men, it is likely that screening has value in addressing the elevated prostate cancer risk and mortality in this group. Without conclusive data from a large RCTs of prostate cancer screening by PSA or other modalities, it is unlikely that guideline or regulatory bodies (eg, USPSTF) will provide screening recommendations specific to African American men. Therefore, screening guidance for this population will largely rely on the evidence presented here. There is an urgent need for additional studies to inform precision prostate cancer screening recommendations for African American men so that we can ameliorate the disparities in prostate cancer outcomes.
Data availability
No new data were generated or analyzed for this review.
Author contributions
Kevin Kensler, ScD (Conceptualization; Formal analysis; Methodology; Writing—original draft; Writing—review & editing), Roman Johnson, PhD (Conceptualization; Data curation; Formal analysis; Writing—original draft), Faith Morley, MPH (Data curation; Formal analysis; Writing—original draft; Writing—review & editing), Mohamed Albirair, PhD (Conceptualization; Investigation; Writing—original draft; Writing—review & editing), Barbra Dickerman, PhD (Conceptualization; Methodology; Writing—original draft; Writing—review & editing), Roman Gulati, PhD (Conceptualization; Investigation; Methodology; Writing—original draft; Writing—review & editing), Sarah Holt, PhD (Conceptualization; Investigation; Methodology; Writing—original draft; Writing—review & editing), Hari Iyer, ScD (Conceptualization; Investigation; Methodology; Writing—original draft; Writing—review & editing), Adam Kibel, MD (Conceptualization; Investigation; Methodology; Writing—original draft; Writing—review & editing), Jennifer Lee, PhD (Investigation; Methodology; Writing—original draft; Writing—review & editing), Mark Preston, MD MPH (Investigation; Methodology; Writing—original draft; Writing—review & editing), Jason Vassy, MD (Investigation; Methodology; Writing—original draft; Writing—review & editing), Erica Wolff, PhD (Conceptualization; Methodology; Writing—original draft; Writing—review & editing), Yaw Nyame, MD (Conceptualization; Methodology; Writing—original draft; Writing—review & editing), Ruth Etzioni, PhD (Conceptualization; Investigation; Methodology; Writing—original draft; Writing—review & editing), Timothy R. Rebbeck, PhD (Conceptualization; Data curation; Formal analysis; Methodology; Project administration; Resources; Supervision; Writing—original draft; Writing—review & editing).
Funding
This work was supported by the National Cancer Institute of the National Institutes of Health under award No. P20CA233255 (to T.R.R.), R00CA245900 (to K.H.K.), R00CA248335 (to B.A.D.), and R50CA221836 (to R.G.).
Conflicts of interest
M.A.P. has received research funds from Merck and has consulting agreements with Pfizer and Bayer. None of these relationships is related to the present paper. No other authors have conflicts to disclosure.
Acknowledgements
The funder had no role in the design of the study; the collection, analysis, or interpretation of the data; or the writing of the manuscript and decision to submit it for publication.
