The Impact of Intensifying Prostate Cancer Screening in Black Men

A Model-Based Analysis

Yaw A. Nyame, MD; Roman Gulati, MS; Eveline A. M. Heijnsdijk, PhD; Alex Tsodikov, PhD; Angela B. Mariotto, PhD; John L. Gore, MD; Ruth Etzioni, PhD


J Natl Cancer Inst. 2021;113(10):1336-1342. 

In This Article

Abstract and Introduction


Background: Black men in the United States have markedly higher rates of prostate cancer than the general population. National guidelines for prostate-specific antigen (PSA) screening do not provide clear guidance for this high-risk population. The purpose of this study is to estimate the benefit and harm of intensified PSA screening in Black men.

Methods: Two microsimulation models of prostate cancer calibrated to incidence from the Surveillance, Epidemiology, and End Results program among Black men project the impact of different screening strategies (varying screening intervals, starting and stopping ages, and biopsy utilization following an abnormal PSA) on disease-specific mortality and overdiagnosis. Each strategy induces a mean lead time (MLT) for detected cases. A longer MLT reduces mortality according to estimates combining the US and European prostate cancer screening trials but increases overdiagnosis.

Results: Under historical population screening, Black men had similar MLT to men of all races and similar mortality reduction (range between models = 21%–24% vs 20%–24%) but a higher frequency of overdiagnosis (75–86 vs 58–60 per 1000 men). Screening Black men aged 40–84 years annually would increase both mortality reduction (29%–31%) and overdiagnosis (112–129 per 1000). Restricting screening to ages 45–69 years would still achieve substantial mortality reduction (26%–29%) with lower overdiagnosis (51–61 per 1000). Increasing biopsy utilization to 100% of abnormal tests would further reduce mortality but substantially increase overdiagnosis.

Conclusions: Annual screening in Black men is expected to reduce mortality more than that estimated under historical screening. Limiting screening to men younger than 70 years is expected to help reduce overdiagnosis.


Data from the Surveillance, Epidemiology, and End Result (SEER) cancer registry demonstrates a persistent two-fold higher rate of prostate cancer mortality among Black men relative to men of other races that has persisted for the last 5 decades.[1] This racial disparity in mortality is currently the most extreme among all cancers in the United States.[2]

As with other cancers, the observed disparity likely reflects complex differences in biological, environmental, social, and health system factors. Various studies in prostate cancer have demonstrated parity in prostate cancer survival from diagnosis when Black and White men are matched by disease severity in the setting of equal access to treatment.[3,4] Yet, in practice, Black men present at younger ages and with more advanced disease than White men in the United States.[5,6] Given the markedly increased incidence of diagnosis among Black men, creating racial parity in prostate cancer mortality will require earlier detection at less advanced stages and appropriate utilization of definitive therapy in Black men with clinically significant disease.

In this article, we study the potential impact of intensifying screening in Black men in an attempt to maximize the early detection of cancers that are curable with definitive treatment. We consider more frequent prostate-specific antigen (PSA) testing and prostate biopsy for abnormal test results as well as different ages for starting and stopping testing. Survey and registry data suggest that PSA screening frequency rates are historically similar between Black and White men in the United States.[7–9] Reports regarding utilization of prostate biopsy for positive tests are mixed, with Barocas et al.[10] reporting lower use of prostate biopsy among Black men in the Prostate, Lung, Colorectal, and Ovarian cancer screening trial and Miller et al.[11] finding that Black men were more likely to undergo prostate biopsy for elevated PSA tests in an updated analysis of the same trial.

A population-level assessment of the impacts of intensifying prostate cancer early diagnosis efforts in Black men has important implications for patients, advocates, researchers, and clinicians working toward equity in racial outcomes. But intensifying screening opens up the potential for increasing overdiagnosis. Therefore, in addition to assessing benefit, we also assess the extent of overdiagnosis under the intensified strategies.