Prostate cancer (PCa) is the most common cancer in men in the United States. However, Black men have an over 2-fold increased risk of PCa death, the largest racial inequality in mortality among all cancers in the U.S.¹ This disparity likely stems from a variety of complex distinctions in biological, socioeconomic, and environmental factors. Black men in the U.S. are more likely to present with PCa at younger ages and with more aggressive disease compared with men of other races. Tsodikov et al found that Black men had an estimated 44%–75% higher risk of progression to metastatic disease by the time of clinical diagnosis when compared to the general population.² On the other hand, racial parity in PCa survival from diagnosis has been established in various studies in equal access settings when matching by disease severity.³ Nevertheless, racial inequalities have been identified in screening practices and this has been exacerbated by the 2012 U.S. Preventive Services Task Force recommendation against routine PSA testing which resulted in an immediate fall in PSA-based screening frequency. The potential adverse impact that national screening recommendations has on PSA testing and outcome in Black men is especially noteworthy given the low representation of Black patients in landmark PCa screening trials (see Table).

Utility of PSA Screening in Black Men

While the magnitude of impact appears heterogenous across age and racial groups, young Black men appear to be most adversely impacted by this trend. Kensler et al analyzed data from a national cross-sectional survey of PSA screening (2012–2018) along with PCa stage-specific incidence trends in Surveillance, Epidemiology, and End Results and demonstrated a modest decline in the frequency of screening in Black men compared to White men. Younger Black men (40–54 years old) were most affected, with a significant decrease in PSA testing frequency compared to White men.⁴ In addition, using data from the Veterans Health Administration, Qiao et al demonstrated that Black men aged 40–55 diagnosed with PCa and without prior PSA screening (compared to those with prior screening) were more likely to have PSA >20 ng/ml, Gleason score ^≥8, metastatic disease, and higher PCa specific mortality.⁵ Undoubtedly, the racially disproportionate burden of PCa coupled with the lack of representation in screening trials, and potential adverse outcomes, warrant specific guidelines tailored to Black men.

The establishment of targeted screening initiatives is imperative to providing Black men with an equitable opportunity to derive the benefit of screening programs. This multifaceted problem lends itself well to the broad potential of intensified early detection strategies. Still, we must carefully weigh benefit-harm tradeoffs. Nyame et al suggest that increasing screening frequency in Black men to annual testing enhances the mortality reduction (to 29%–31%) but also significantly increases overdiagnosis (to 112–129 per 1,000 men). Alternatively, restricting screening to ages 55–69 years produces a smaller mortality reduction (18%–20%) but a more acceptable rate of overdiagnosis (30–33 per 1,000 men).⁶ A 2017 analysis of race-specific patterns of PCa before and after PSA screening estimated the cumulative risk of developing potentially fatal PCa among Black men at any given age parallels that in the general population up to 10 years older. Thus, the investigators suggested Black men may benefit from screening 10 years earlier than the general population. Despite these data, many studies have adequately illustrated that Black and White men have similar PCa outcomes when matched for age, stage, and grade in the setting of equal treatment.^6,7 Though we emphasize its importance, targeted screening with PSA, imaging adjuncts, and any potential novel tests should be implemented selectively, accounting for family history, genetic risk, and life expectancy >10 years. Furthermore, a more intensive screening regimen may dissuade Black men, a community with a known and justified mistrust of the health care system, from seeking support entirely. On the contrary, less frequent screening may result in missing a small window of early detection, significantly negating the benefit of screening. Working towards identifying that “sweet spot” is therefore of utmost importance.

Screening and Detection Strategies in Black Men

A fundamental stride towards diminishing PCa disparities includes determining the efficacy of screening measures in Black men and ultimately how to maximize these through meaningful adjustments. Identifying Black men at highest risk of PCa specific mortality is an essential first step; additionally, judicious utilization of adjunct multiparametric magnetic resonance imaging (mpMRI) may help to select those who would benefit from more intense screening and invasive testing (ie biopsy) while reducing the harm of overdiagnosis. mpMRI has been established as an important tool for the detection of clinically significant PCa, however there is significant disparity in use, particularly among Black men.⁸ When evaluating prostatectomy specimens in patients with pathological upgrading from ultrasound-guided biopsy to final prostatectomy, the dominant lesion was more often anteriorly located in Black men (59% vs 0%).⁹ These data suggest that mpMRI should be considered in Black men prior to biopsy to rule out significant foci of anterior disease that may be missed by standard systematic templates. Furthermore, increased use of mpMRI to detect clinically suspicious lesions in Black men found to have elevated PSA by screening may decrease overdetection of nonlife-threatening cancer and abrogate the potential harm of earlier and more intense screening.

An enterprise worthwhile is mending Black men’s mistrust of the health system through education, church gatherings, and mobile screenings. Murphy et al promote the utilization of barbershops as culturally relevant venues for health promotion delivery and disease prevention services, subsequently diminishing access barriers. Thomas Farrington, a 20-year PCa survivor, founded the Prostate Health Education Network (PHEN) with a focus on addressing PCa racial disparities through patient education and awareness webinars and clinical trial rallies. PHEN also began partnering with churches in 2009 and has since worked with more than a thousand churches nationwide. Notably, in 2006 PHEN introduced the concept of resolutions to address the African American PCa crisis, urging federal agencies to address the health crisis through education, outreach, and research specifically focused on African American men. Additionally, the power and influence of athletes and celebrities must not be underestimated. A recent example was demonstrated by TODAY show anchor and PCa survivor Al Roker who made it a point to inform people by discussing his own journey with the disease and its treatments, with special focus on those within the Black community.

It is also important to have a careful, unhurried, and well-focused discussion with Black men regarding the importance of screening. Approaches that immediately move to biopsy or other invasive diagnostics for marginal elevations in PSA may deter Black men from engaging with the system and process. We should seek to adopt an approach that aims to determine that a biopsy is not warranted and is safe to omit due to predetermined and acceptably low pre-test probability of cancer presence, rather than biopsy being the default position. To this end, improved engagement and confidence may be realized.

Future Directions

Representation in the research and development space is critical. Prior to Food and Drug Administration acceptance and subsequent clinical guideline recommendations, any potential new PCa screening test should be sufficiently studied and validated in Black populations. A goal of a minimum of 20% Black participants should be sought for novel PCa tests. A 2020 review of 72 global phase 3 and 4 PCa clinical trials found an overwhelmingly high proportion of White participants, comprising over 96% of the study population.¹⁰ Studies have shown that minorities are more likely to participate in trials when research personnel are from the same racial, cultural, and/or linguistic background, or when they are enrolled through trusted institutions such as places of worship and community-based organizations. Therefore, racial diversity and representation among physicians, researchers, clinical staff, and patient advocates is extremely important to disseminate the message of PCa screening in Black men. Workforce diversity is an ongoing area of focus for many urology training programs but should be for all. Our colleagues provide better care and our institutions will be more highly regarded when the workforce is representative of the population. Acute awareness of health inequity is at an all-time high. In the age of refined screening approaches, precision diagnostics, and individualized directed therapies, the implementation of PCa screening guidelines tailored to Black men must be designated as a high priority. Finally, the inclusion of Black physicians and researchers on any guideline committee for PCa screening is crucial to ensuring racially diverse and purposeful advocacy to maximize the benefit of expert opinion.