Racial Disparity in Men Undergoing Varying Intensity of PSA Screening in a Large, Racially-diverse Population

David Ambinder, MD

Race may impact outcomes in prostate cancer regardless of rates of prostate specific antigen (PSA) screening, according to the results of a study presented at the 2021 annual meeting of the Society of Urologic Oncology, held  December 1-3. Sami Majdalany, MD, research fellow at the VattikutiI Center for Outcomes Research Analytics and Evaluation, at Henry Ford Cancer Institute, Detroit, reported a study that revealed differences in PSA screening rates but also in tumor characteristics seen at diagnosis between African American and White men in a diverse population.1

Data are lacking on PSA screening outcomes  in African American men, Dr Majdalany noted, citing as typical the landmark Prostate, Colorectal, Lung, and Ovarian (PCLO) Cancer Screening Trial, in which only around 4% of men enrolled in the prostate component of the trial were African American.2 A number of studies have addressed rates of PSA screening among African American versus White men in the United States, but  whether PSA screening intensity has a differential impact on prostate cancer diagnoses in African American men has remained unclear, with a lack of Level 1 evidence and of a clear guideline from the United States Preventive Services Task Force (USPSTF), Dr Majdalany stressed.

The racially diverse population of Southeastern Michigan served by Henry Ford Health System allowed researchers at Henry Ford Hospital to investigate this association in African American men compared with White men. Dr Majdalany and his colleagues identified men aged ≥45 years without a prior prostate cancer diagnosis and at least one PSA test between 1995 and 2019. All these men had remained in the system for at least 6 years.

Screening intensity was assessed over a 5-year window. Over the duration of follow-up within the study, routine screening was defined as undergoing at least one PSA testing every 1-2 years; occasional screening as undergoing at least one PSA screening every 3 years; and sporadic screening as men who had no PSA testing for 3 consecutive years.

A total of 135,498 men were identified, around 33% in each screening group, of whom 34,623 (25.6%) were African American. African American men were significantly younger than White men at the time of their first PSA test (median age 54.9 vs 57.8 years, respectively, P<0.001). However, African American men were significantly less likely than White men to undergo routine PSA screening (29.4% vs 33.6%, P<0.001).

Over a median follow-up of 9.5 (5.9-15.3) years, the cumulative incidence of prostate cancer diagnosis was higher in African American men than in White men in each PSA screening group: sporadic, 3% vs 1%, respectively; occasional, 5% vs 2%; and routine, 9% vs 4% (all P<0.001).

Similar differences were seen between African American and White men at the time of prostate cancer diagnosis. Among participants who underwent occasional intensity screening, African American men had a higher PSA than White men at the time of diagnosis (median PSA 6.8 ng/dL vs 5.6 ng/dL, respectively, P<0.001). African American men also had a higher likelihood than White men of having clinical nodal positive disease  (2.1% vs 1.5%, P<0.001) and of having metastatic disease (9.9% vs 9.1%, P<0.001) at diagnosis. Similar trends were seen in participants who underwent sporadic screening: median PSA 8.8 ng/dL vs 6.3 ng/dL (P<0.001); positive clinical nodal disease 4.2% vs 3.5% (P<0.001), and metastatic disease 17.7% vs 13.0% (P<0.001).

On behalf of his colleagues, Dr Majdalany concluded that the results from this large, equal access, racially diverse, US-based study showed that over a 20-25 year period, fewer African American men underwent PCLO-defined routine PSA screening. Equally important, Dr Majdalany stressed, was the finding that African American men who underwent occasional or sporadic PSA testing had significantly worse tumor characteristics at diagnosis than their White counterparts with similar PSA screening intensity.

These results indicated that while there may be differences in access to health care, within a given screening category, African American men had worse tumor characteristics, suggesting intrinsic differences in tumor biology between African American and White men, Dr Majdalany stated. This is hypothesis-generating and ongoing studies involving multiple institutions, including Henry Ford Hospital, are seeking to identify a genetic basis and genetic polymorphisms that underlie these differences, he noted.

David Ambinder, MD is a urology resident at New York Medical College / Westchester Medical Center. His interests include surgical education, GU oncology and advancements in technology in urology. A significant portion of his research has been focused on litigation in urology. 

References 

  1. Daiela A, Jamil M, Sood M, et al. Racial disparity in prostate diagnosis for men undergoing varying intensity of prostate-specific antigen (PSA) screening in a large, racially diverse healhcare system. Poster #70 presented at the 22nd Annual Meeting of the Oncology of Urologic Oncology (SUO), December 1-3, 2021. https://suo-abstracts.secure-platform.com/a/gallery/rounds/12/details/1563 Accessed January 1, 2022.
  2. Andriole GL, Crawford ED, Grubb RL III, et al; PLCO Project Team. Prostate cancer screening in the randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: mortality results after 13 years of follow-up. N Engl J Med. 2019; 104(2):125-132. DOI: 1093/jnci/djr500