Prostate-specific antigen (PSA) screening is meant to help detect prostate cancer at an early stage and lower the risk of death. Research has shown that Black men are more likely than white men to develop and die of prostate cancer. Now, study results published in Cancer suggest that Black men are at greater risk even when they have PSA levels similar to those of their white counterparts.

“The findings indicate that at any given PSA level, Black men are more likely to harbor prostate cancer than white men,” wrote the study authors. “Prospective studies are needed to better evaluate risks and benefits of PSA screening in Black men and other high-risk populations.”

Kyung Min Lee, PhD, of the VA Salt Lake City Health Care System in Utah, and colleagues compared prostate cancer risk for Black and white people, considerin their PSA levels prior to a biopsy.

The study population included 75,295 Black and 207,658 white male veterans who received medical care through the Department of Veteran Affairs. The researchers considered several predictors of risk: self-identified race, age at first PSA test, PSA levels before biopsy, age at first biopsy, smoking status, statin use and socioeconomic factors. With the help of modeling, they predicted the odds of prostate cancer detection during the first biopsy when considering different PSA levels.

The researchers found that Black veterans were 50% more likely than white men to have prostate cancer detected on their first biopsy, after accounting for PSA levels and other variables. On their first biopsy, 55% of Black men were diagnosed with prostate cancer compared with 43% of white men.

At a PSA level of 4.0 nanograms per milliliter, the risk of prostate cancer was 49% for Black men compared with 39% for white men. The model suggested that a PSA level of 4.0 ng/mL puts Black men at equal risk as a level of 13.4 ng/mL for white men.

The U.S. Preventive Services Task Force recommends that men between ages 55 and 69 should make an individual decision about PSA screening in consultation with their doctor. That recommendation, issued in 2018, is currently under review. The new findings imply that Black men may need earlier and more frequent screening.

In contrast, the American Cancer Society recommends that men at average risk should start PSA screening at age 50, those at high risk—including Black men and men with a father or brother who was diagnosed with prostate cancer before age 65—should start at age 45, and those at even higher risk should do so at 40. The Prostate Cancer Foundation now suggests that Black men should begin PSA screening at ages 40 to 45. 

At the recent ASCO Genitourinary Cancers Symposium, researchers reported that lowering the screening age could reduce prostate cancer deaths for Black men without substantially increasing the rate of overdiagnosis. Another study showed that a different test called Stockholm3—which incorporates PSA, three other cancer-related proteins (GDF15, KLK2 and PSP94), polygenic risk and clinical data—is equally good at detecting prostate cancer but with fewer false positives, enabling many men to avoid unnecessary biopsies.

“These findings suggest that to reduce health disparities for veterans in the prevention of prostate cancer, clinicians should consider an individual veteran’s risk for prostate cancer, including factors such as race and age,” Lee said in a press release. “Clinicians may consider earlier screening for populations at greater than average risk, which includes Black men.”

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