At same PSA level, Black men more likely than white men to have prostate cancer
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At any given PSA level, Black men are more likely than white men to harbor prostate cancer, according to analyses of a Veterans Health Administration cohort.
Prospective studies are necessary to further assess the benefits and risks of PSA screening for Black men and other populations at high risk for prostate cancer, researchers concluded.
“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,” Kyung Min Lee, PhD, of VA Informatics and Computing Infrastructure, part of the VA Salt Lake City Health Care System, said in a press release. “Clinicians may consider earlier screening for populations at greater than average risk, which includes Black men.”
Black men are more likely than non-Hispanic white men to develop prostate cancer. They also are more likely to die of the disease.
However, there is limited evidence to guide PSA screening protocols for Black men, according to study background.
Lee and colleagues assessed whether self-identified Black veterans had a higher risk for prostate cancer than white veterans based on prebiopsy PSA levels.
Researchers used data from the Veterans Health Administration (VHA)’s Corporate Data Warehouse — which provides access to electronic health record data for veterans nationwide who received care through the VHA.
The study sample included white and Black veteran men who underwent their first prostate biopsy in the VHA system between October 1999 and September 2021.
Exclusion criteria included prior prostate cancer diagnosis, radical prostatectomy, radiation therapy or androgen deprivation therapy. Researchers also limited the cohort to men who had at least one PSA test in the 1 year prior to their initial biopsy and who did not die in the 90-day period after first prostate biopsy.
The analysis included 207,658 white male veterans and 75,295 Black male veterans.
Investigators performed multivariable logistic regression to estimate the likelihood of prostate cancer diagnosis on first biopsy. They used several factors as predictors, including self-identified race, age at first PSA test, age at first biopsy, prebiopsy PSA, statin use, smoking status and socioeconomic factors.
Black men were younger than white men when they underwent their first PSA test (median, 56 years vs. 61 years) and first prostate biopsy (media, 63 years vs. 65 years).
Analyses controlled for covariates — including PSA and smoking status — showed Black veterans had a 50% higher risk than white veterans to receive a prostate cancer diagnosis on their first biopsy (HR = 1.5; 95% CI, 1.47-1.53).
This difference appeared even greater among younger men ( 60 years; OR = 1.82; 95% CI, 1.76-1.88) than older men (ages 61 to 70 years, OR = 1.43; 95% CI, 1.4-1.47; 70 years or older, OR = 1.17; 95% CI, 1.12-1.22).
Likelihood of prostate cancer detection appeared consistently higher among Black men than white men across the prebiopsy PSA range of 2.0 ng/mL to 20 ng/mL, results showed.
At an equal PSA level of 4.0 ng/mL, Black men had a 49% probability of prostate cancer, whereas white men had a 39% probability of prostate cancer.
Based on this model, a Black veteran with a PSA of 4.0 ng/mL would have a prostate cancer risk equivalent to a white veteran with a PSA of 13.4 ng/mL.
Analyses adjusted for PSA, smoking status and other selected covariates showed Black men had higher risk than white men for diagnosis of aggressive prostate cancer (OR = 1.3; 95% CI, 1.27-1.33).
“Clinical trials of prostate cancer screening used PSA levels of 2.5 to 4.0 ng/mL as a threshold for biopsy, although in practice, both Black and white men were referred at higher PSA levels ... which may reflect an attempt to reduce overdiagnosis of indolent cancer,” Lee and colleagues wrote. “Our results suggest that Black men are at substantial risk [for] prostate cancer, including aggressive prostate cancer, at lower PSA levels.
“Undergoing PSA screening is an individual decision, but these findings suggest that men at high risk [for] prostate cancer who choose PSA screening should consider lower biopsy thresholds consistent with clinical trials,” they added. “Our results suggest that adherence to more intensive guidelines, such as the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Prostate Cancer Early Detection, could potentially lead to reduced prostate cancer disparities. However, decisions to increase early intervention should be informed by the potential for harms such as prostate biopsy complications and overdiagnosis.”
References:
- At the same PSA level, Back men are more likely to have prostate cancer than white men (press release). Available at: https://www.eurekalert.org/news-releases/1006379. Published Nov. 6, 2023. Accessed Nov. 6, 2023.
- Lee KM, et al. Cancer. 2023;doi:10.1002/cncr.34979.
Perspective
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Samuel Haywood, MD
It is well-established that Black men have higher risk for prostate cancer and higher risk for aggressive prostate cancer. Despite this, the available professional guidelines for prostate cancer screening have inconsistent recommendations regarding any special screening that should be considered to incorporate this predisposition into practice.This article providers tangible evidence regarding the differential prostate cancer risk between Black and white men at various PSA levels. In particular, Black men have significantly higher rates of prostate cancer than white men at the same PSA level, and they are more likely to receive diagnosis of prostate cancer on their first biopsy.
This would suggest that we should consider lower thresholds for evaluation of elevated PSA among Black men. That said, specific ages to begin screening or triggers for biopsy remain unknown.
In past years, we as a field have tried to limit prostate biopsy at lower PSA levels in an attempt to avoid overdiagnosis and prevent overtreatment. However, this strategy, while well-intentioned, may unintentionally underscreen Black men and miss an important opportunity for early diagnosis.
It is important that future research delve further into specific considerations such as the appropriate age or PSA threshold for Black men to help guide our clinical practice.
As I tell my patients, in most aspects of life in modern society we try to remove race from the equation; however, this is one particular instance where we must consider race in order to provide the best care for our patients. The adoption of more aggressive screening regimens will hopefully allow us to narrow or eliminate the disparities present in prostate cancer.
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