Black men in the U.S. have demonstrated a persistent, twofold higher risk of prostate cancer mortality that has been well-documented since the inception of the Surveillance, Epidemiology, and End Results (SEER) program in the 1970s. This inequity in prostate cancer outcomes is driven by a variety of factors, which include a nearly 80% higher incidence of disease that is further compounded by a variety of social, environmental and health factors. Estimates of the natural history of prostate cancer in the U.S. demonstrate younger ages of disease onset and a greater risk of progression to advanced disease among Black men.¹ These differences in prostate cancer onset, aggressiveness and outcomes highlight the need to translate health services and clinical interventions into better outcomes for Black men.

The early detection of prostate cancer has coincided with a 50% decrease in prostate cancer mortality since the introduction of prostate specific antigen (PSA) testing in the late 1980s.² Routine PSA testing carries the risk of overdetection, overtreatment and adverse biopsy-related sequelae, especially among men with clinically insignificant cancers. This must be balanced with the long-term benefit in mortality reduction demonstrated in one of the randomized clinical trials for PSA screening,³ which is estimated to continually accrue even up to 25 years after screening initiation.⁴ In 2018, the U.S. Preventive Services Task Force (USPSTF) changed its 2012 recommendation against routine PSA testing to a Grade C recommendation that advocates for shared decision making around PSA testing between men ages 55–69 years and their doctors.⁵ Despite the increased risk of incidence and mortality, the USPSTF did not provide specific guidance for early detection in Black men, stating that “it is problematic to selectively recommend PSA-based screening for Black men in the absence of data that support a more favorable balance of risks and benefit.”⁵

Population-level data provide us with valuable insight about the natural history of prostate cancer among Black men that can be used to inform and study a variety of strategies for early detection. To understand where the opportunities exist to translate an early detection intervention into a mortality benefit requires consideration of 3 key questions: 1) Are current screening practices equitable?, 2) What is an equitable screening practice?, and 3) What are the costs, harms and benefits of achieving equitable screening? Historically, the rates of prostate cancer screening among Black men have been similar to those of nonHispanic white men; however, the rates of screening declined more significantly among Black men following the 2012 USPSTF recommendation against screening, leading to a modest disparity in PSA testing.⁶ Defining an equitable strategy for early detection should take into account the natural history of prostate cancer among Black men. The application of the same screening strategy may fail to provide Black men with the same opportunity to benefit from early detection given the higher incidence, younger age of onset, and the potential for more aggressive disease. This difference in natural history can translate into different benefits and harms based on the intensity of screening (ie age of screening, frequency of screening and frequency of prostate biopsy).

Figure 1. Changes in prostate cancer incidence (overdetection) and mortality under no screening and historical early detection strategies for all races and under no screening, historical and intensified early detection strategies for Black men projected by the Fred Hutchinson Cancer Research Center model (A) and the Erasmus Medical Center MIcrosimulation SCreening ANalysis model (B). Lines connect results for each race group.

Figure 2. Total prostate cancer diagnoses, screen detections and overdetected cases per 1,000 men under no screening and historical early detection strategies for all races and under no screening, historical and intensified early detection strategies for Black men projected by the Fred Hutchinson Cancer Research Center model (A) and the Erasmus Medical Center MIcrosimulation SCreening ANalysis model (B). Results for strategies with and without age restrictions are shown separately.

To test the impact of these screening strategies, we utilized 2 established models of prostate cancer natural history to project the impact of intensified screening among Black men.⁷ We first started by evaluating the impact of historical screening practices, which were informed by screening patterns reported in the National Health Interview Survey and the SEER-Medicare database and biopsy practices in the Prostate, Lung, Colorectal, and Ovarian Cancer (PLCO) screening trial, ie biennial PSA testing among men 40–84 years old with 40% biopsy of positive tests defined as PSA >4 ng/ml.⁷ We then tested a variety of screening strategies varying the frequency of PSA testing and rate of prostate biopsy utilization. We also repeated these analyses with earlier starting ages of screening and with screening cessation at age 70 years as recommended by the USPSTF. Benefit was reported as the relative reduction in mortality compared to no screening, and harm was defined as the number of overdetected per 1,000 men screened.

Our results demonstrated a similar benefit of early detection with PSA testing under historical practices with mortality reduction ranging from 21%–24% among Black men to 20%–24% of men of all races (fig. 1). However, historical screening practices were associated with a higher frequency of overdetected cancers for Black men (75–86 per 1,000 men) compared to men of all races (58–60 per 1,000 men; fig. 2). Annual screening of Black men between the ages of 40–84 years led to an increase in mortality reduction (29%–31%) at the cost of a significant increase in overdetected cancers (112–129 per 1,000 men). By restricting the age of screening from 45–69 years, annual PSA testing could still achieve a substantial mortality reduction (26%–29%) with lower overdetections (51–61 per 1,000 men) when compared to historical practices. Lastly, increasing the frequency of prostate biopsy did further reduce mortality among Black men, but did so at the cost of increasing overdetected cases.

These findings suggest that annual PSA testing starting at age 45 years can reduce prostate cancer mortality among Black men beyond current screening practices. Appropriate cessation of PSA testing at age 70 retained this benefit, while reducing the risk of overdetecting clinically insignificant cancers that would harm some Black men. Our analysis provides high-quality evidence in support of a tailored screening strategy for Black men that aims to reduce the inequitable mortality burden in the population. This is needed given that Black men only represent 0%–3% of men in the 2 large screening trials conducted to date.⁸ The main limitation of our analysis is that it represents hypothetical scenarios that do not accommodate the social and health barriers to health care access and utilization for Black men in the U.S.

For these policy recommendations to have impact, we must be willing to invest in patient-centered studies and initiatives rooted in community-engagement to devise robust strategies for translating these policy recommendations around prostate cancer early detection into an equitable practice for Black men in the real world. We must also invest in systems to surveil and assess the efficacy of these tailored screening practices, and must be willing modify these recommendations if their harms ever outweigh their benefits.