| 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.
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