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Prostate cancer screening

"Critically important for African American men to get screened"

“African American men tend to get more aggressive prostate cancer that metastasizes,” says Eldra Daniels, MD, a family physician with the Penn State Health Medical Group.

“They are getting diagnosed twice as much as Caucasian men, and their cancers are found at later stages. They might go to the doctor for back pain only to learn that it’s not arthritis, but instead is prostate cancer that had metastasized to their bones.

It is critically important they get screened for this cancer.” 

See “Prostate cancer risks in African American men” on the Penn State College of Medicine News website (October 25, 2021)

"Make sure you're going to be around for your family"

“You can ignore it at your own peril. But if you love your family, love what you do, love the people around you, you’ve got to get screened. There’s no stigma to it. Just get it done. Make sure you’re going to be around for your family,” says television personality and prostate cancer survivor Al Roker.

“The problem with prostate cancer is there’s generally no outward symptoms. But if there are symptoms, you’re pretty well down the line with the progression of the disease.  What’s the big deal? You just have to do it.”

A 2-minute video from The Patient Story.

The PSA test

PSA, or Prostate-Specific Antigen, is a protein produced by normal, as well as malignant, cells of the prostate gland. The blood level of PSA is often elevated in men with prostate cancer. However, PSA levels can also rise because of some some non-cancerous conditions, such as inflammation of the prostate and enlargement of the prostate. Most organizations recommend that men who are considering PSA screening first discuss the risks and benefits with their doctors.
Source: National Cancer Institute. Prostate-Specific Antigen (PSA) Test (2021)

American Cancer Society

The American Cancer Society recommends that beginning at age 45, black men who are at average risk of prostate cancer and have a life expectancy of at least 10 years have a conversation with their health care provider about the benefits and limitations of PSA testing and make an informed decision about whether to be tested based on their personal values and preferences.
Source: American Cancer Society. Cancer Facts & Figures for African Americans 2019-2021. Atlanta: American Cancer Society, 2019.

U.S. Preventive Services Task Force (USPSTF)

For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; over-diagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction.

For men 70 years and older, the USPSTF recommends against PSA-based screening.

For African American men, the USPSTF is not able to make a separate, specific recommendation on PSA-based screening for prostate cancer based on the available evidence. Decision analysis models suggest that given the higher rates of aggressive prostate cancer in African American men, PSA-based screening may provide greater benefit to African American men than the general population. These models also suggest a potential life-saving benefit for African American men when beginning screening before age 55 years.

The USPSTF believes that a reasonable approach for clinicians is to inform African American men about their increased risk of developing and dying of prostate cancer as well as the potential benefits and harms of screening so they can make an informed, personal decision about whether to be screened.

Source: U.S. Preventive Services Task Force (2018). The U.S. Preventive Services Task Force is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine who make evidence-based recommendations about clinical preventive services. Most private insurance plans are required to cover without a copay recommended preventive services that receive a grade of A or B from the Task Force.

"We encourage all men to have a conversation with their doctor about PSA screening"

The American Cancer Society’s 2022 Cancer Facts & Figures shows that death rates for cancer overall continue to decline for both men and women. However, the report also reveals that the death rate from prostate cancer is no longer declining as quickly, says Charles J. Ryan, MD, CEO of the Prostate Cancer Foundation (above).

“A main reason is that more men are being diagnosed at an advanced stage. For these patients, the 5-year survival rate is only 31%. Additionally, the disparities in prostate cancer incidence and death between Black and White men remain unacceptably high.”

“Survival from prostate cancer is significantly improved when caught early. Catching the disease early involves a conversation between a man and his doctor, as well as a physical exam and PSA testing. We encourage all men to have a conversation with their doctor about PSA screening and a conversation with their family about cancer history.”

Source: Prostate Cancer Foundation (January 14, 2022)

Digital rectal exam

“My actual doctor is going to insert his actual finger into my actual rectum to examine my actual prostate. And there he goes, he’s all the way in and he’s looking around…”

Television personality Mike Rowe has a digital rectal exam on camera to show how easy and quick (though briefly uncomfortable) it is to get your prostate checked. 

A 2-minute humorous video from the prostate cancer support group ZERO — The End of Prostate Cancer. 

Should you get your PSA level tested?

Knowing your PSA level can help determine your chance of having prostate cancer.

However, the PSA test can have negative consequences, as well. PSA levels are sometimes high when cancer isn’t present. And testing can’t always tell which prostate cancers are deadly and which ones won’t cause problems.

A 2-minute video from the Centers for Disease Control and Prevention ( CDC).

About the PSA test

“We use PSA in a few different ways to  think about your risk for prostate cancer,” says Adam Feldman, MD, of the Massachusetts General Hospital Department of Urology.

“One is looking at it over time.  So sometimes it’s elevated and if we just get one snapshot in time it may just be your baseline PSA. We also try and look at it in relation to your age and to the size of your prostate. We know that a larger prostate will make more PSA.”

A 2-minute video from the Massachusetts General Hospital.

Why Controversy over PSA test?

After years of widespread PSA screening, the U.S. Preventive Services Task Force in 2012 made the controversial decision not to recommend routine PSA testing on the grounds that too few lives are saved to justify all the harm that’s done treating healthy men.

Five years later in 2017, the Task Force changed its stance, recommending that the decision whether or not to do PSA screening should be made individually for each man aged 55 to 69. This new position has been criticized for not taking into account that African American men are more likely to be diagnosed at younger ages and with more aggressive tumors compared with White men.
Source: “USPSTF Backtracks, Now Says PSA Test Is ‘Individual Decision'” by Liam Davenport on the Medscape website (May 8, 2018)

"We don't have adequate screening data for African American men"

Despite the fact that African American men are much more likely to develop and die from prostate cancer as White men, “young African American men are poorly represented in PSA studies from which evidence-based guidelines are developed,” says Lori J. Pierce, MD, President of the American Society of Clinical Oncology.

“So, this really limits proper PSA guidance screening guidance for African American patients, especially for those who are younger than 55. And so, because we don’t have adequate screening data, there are differences in opinion as to what the guidelines should be.”

Source: “Younger African American Men With Prostate Cancer Show Improved Outcomes With More PSA Screenings.” (May 20, 2021)

"We need more studies to know what's right for high-risk men"

“One of the problems we have with the science is thinking about high-risk men,” says Alex H. Krist, MD, Chair of U.S. Preventive Services Task Force. The Task Force has not made any specific recommendations about screening in African American men.

“So men who are African American or men who have a family history of prostate cancer? Does screening help them any more than an average-risk man? We also don’t know if they have greater harms from the whole screening process. We need more studies to know what’s right for high-risk men.”

Source: “Screening for Prostate Cancer ,” a 3-minute video from the U.S. Preventive Services Task Force (October 9, 2018) The Task Force

American Cancer Society: Advances have lessened over-detection and over-treatment from PSA testing

“Controversy remai ns about the underutilized potential of the PSA test for re ducing prostate cancer mortality by detecting potentially fatal disease earlier. The value of screening is especially salient for Black men, who have had a steeper drop in PSA testing than White men despite two-fold higher prostate cancer mortality.

Proponents of testing are bolstered by advances in mitigating over- detection and over-treatment through more stringent diagnostic criteria and active surveillance for low-risk disease.

In addition, promising new approaches to screening that include the use of molecular markers and magnetic resonance imaging-targeted biopsy have demonstrated success in the detection of clinically significant cancer with limited over-detection.”
Source: American Cancer Society. Cancer statistics 2022.

New Research About Prostate Cancer Screening in Black Men

Opinions About Earlier Prostate Cancer Screening

"Black men should start PSA screening earlier"

“When we are discussing early-stage prostate cancer, there are no early warning signs or symptoms,” says radiation oncologist Jerome M. Butler, MD, of North Carolina.

“Given that we know that African American males have a higher risk of prostate cancer, we believe that prostate cancer screening cannot be ignored.

For asymptomatic men of average risk, prostate screening should begin at ages 55 to 69. We believe that African American males should start earlier.”

A 3-minute video from the SERO Radiation Oncology Group of Charlotte, North Carolina

"Know your prostate health beginning at age 40"

“All Black men are at high risk for prostate cancer,” says Thomas Farrington, founder of the Prostate Health Education Network (PHEN) and a prostate cancer survivor.

“It is very important to know your prostate health. Knowledge is the best defense against prostate cancer. You begin that by knowing the health of your prostate.

So we recommend that men begin early detection testing to know their prostate health beginning at age 40 using a PSA test and the digital rectal exam. Because early detection is so crucial to beating this disease should you be diagnosed with it.”

A 1-minute video from the Dana-Farber Cancer Institute.

Should Black men get their PSA levels checked? 

Yes, says Richard Kennedy, MD, whose prostate cancer was discovered after a high PSA test.

“The dilemma is in people of color, we die at greater rates with prostate cancer, we tend to have more aggressive cancer at the time of diagnosis than other populations. So for us, it’s different. We tend to be always at the end of the scale. Prevention is the key,” says Kennedy.

“The one thing that has been proven over time is that most disease when it does affect people of color, it tends to be more aggressive. That’s probably happening more because we show up late. “

A 2-minute segment of a 6-minute video.

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