Special Considerations for PSA Screening in Black Men

Prostate cancer screening with a prostate-specific antigen (PSA) blood test should follow a “shared decision-making” approach. In order to make a PSA screening plan that is best for each man, the goal of shared-decision making includes balancing the patient’s wishes and desires with guideline recommendations, as explained by his doctor. This conversation should focus on the harms and benefits of a PSA screening plan. Most urologists in the United States rely on the American Urological Association (AUA) guidelines to counsel patients for PSA screening. Generally, these guidelines suggest that:

  • For men between 55 and 69 years of age, the decision to have PSA screening involves weighing the benefits of reducing the rate of metastatic (i.e., advanced) prostate cancer and prevention of prostate cancer death against the known potential harms associated with screening and treatment
  • Most men outside of the ages of 55 to 69 years do not benefit from PSA screening

However, Black men in the United States are approximately 60% to 80% more likely to be diagnosed with prostate cancer and twice as likely to die from prostate cancer compared to men of other races. Unfortunately, men that are racial minorities are underrepresented in the two key randomized clinical trials that have been used to inform guidelines on prostate cancer screening.

Even though there are important nuances to PSA screening that are essential and unique to Black men, the data is somewhat more limited. Plus, several experts in the field suggest that based on the greater risk of prostate cancer in Black men, there should be tailored national guidelines for this at-risk population.

In general, because of their higher risk of prostate cancer, Black men may benefit from starting PSA screening at an earlier age. Research suggests that Black men should be eligible for screening 3 to 10 years before the general population because of their risk of developing potentially fatal prostate cancer at a younger age (for example 40 or 45 years of age) which parallels the risk in the general population up to 10 years older (for example 50 or 55 years of age). Based on the AUA guidelines recommendations for screening between 55-69 years of age, this would mean starting screening for Black men at age 45. The NCCN (National Comprehensive Cancer Network) guidelines also recommend beginning screening for Black men at 40 to 45 years old.

Even if beginning screening in younger Black men leads to more low-grade, low-volume prostate cancer cases being diagnosed, many studies have shown that active surveillance is safe among Black and white men (even at a young age). This avoids the harm of overtreatment in these situations.

It is also important to note that there may be differences in the PSA level between Black men and white men. Several studies suggest that Black men with localized prostate cancer have higher PSA levels at diagnosis compared to white men. Other studies suggest that among men without prostate cancer, Black men have a higher PSA density (PSA level divided by the size of the prostate – or commonly referred to as prostate volume) than white men.

Because studies looking at the impact of race on PSA velocity (the change in PSA over the course of time) are inconclusive, it may be wise to not only start PSA screening earlier but to also to check PSA more often among Black men (when clinically indicated) to better understand a man’s PSA velocity, or change in PSA.

As Black are more likely to be diagnosed with prostate cancer at younger ages and with more aggressive disease, a personalized PSA screening recommendation may be advised. Young Black men in particular should engage at an early age with their doctor in a shared decision-making fashion regarding the risks and benefits of PSA screening for prostate cancer.

Zachary Klaassen, MD, MSc
Urologic Oncologist, Georgia Cancer Center, Augusta University, Augusta, GA, USA