In May of this year, the results of a new population-based analysis performed by research at the Keck School of Medicine at the University of Southern California (USC) were released showing that from 2004 to 2018, there has been an increased incidence of metastatic prostate cancer in men of all ages, especially in men ages 75 and older.
For years, we’ve been encouraged in primary care to follow a shared decision-making approach to discuss with men, particularly those who are 55 to 69 years of age, their individual risks of prostate cancer. This approach was influenced by recommendations from the United States Preventive Services Task Force (USPSTF) in its 2018 update to previous recommendations on prostate cancer screening.
Earlier iterations of recommendations for this preventive measure started in 2008, when for men over 75 years of age and then for all men in 2012, the guideline body recommended against screening for prostate cancer. Needless to say, these updates potentially fostered more confusion than clarification for adherent clinicians.
This new analysis offers evidence for a needed paradigm shift in our approach to screening for prostate cancer, and this could not have come at a better time than now, specifically for Black men.
African American men are disproportionately impacted by new diagnoses of prostate cancer, and at the point of diagnosis their cancers are often more aggressive and are already metastatic. Smoking and excess body weight may increase one’s risk of more aggressive and fatal disease. That we know. That is why screening for prostate cancer is so crucial for early detection, treatment initiation and to help provide for the best possible prognosis.
In light of this, in 2018 the American Urological Association (AUA) recommended that a man of African descent may start screening as early as 40 years of age, instead of at age 55, if there is a positive family history in a close male relative, listing African American race as a factor of high risk and that the decision should be individualized.
These guidelines aid in providing clarification where the USPSTF guidelines did not and exist as a tremendous godsend in having these crucial discussions with men of African descent. Therefore, this practice of screening for prostate cancer is the preferred procedure to follow for Black men and has led to early detection of many cancers. This is how I proceed in my own practice, and benefits versus risks of screening always have a place in the discussion.
Despite many physicians being aware of this and following this practice, African-American men continue to be diagnosed with and die from metastatic prostate cancer, and this is a trend that desperately needs to be reversed. We have adequate screening tools that do not even require a digital rectal examination. The Prostate Specific Antigen (PSA) blood test, though it may elevate in infectious and inflammatory conditions affecting the prostate gland, is more accurate than the digital rectal examination in helping to detect prostate cancer.
Men of color need to be made aware of this, because many still are remarkably nervous when it comes to even the thought of discussing prostate cancer screening for fear of the proverbial “finger test.” It is also incumbent upon the patient to discuss with male relatives his family history, which is so crucial in having those discussions with his primary care physician to determine the best age, together, at which to commence screening. In this respect, knowledge, without fear of contradiction, is truly power and equates to years lived.
Prostate cancer screening and the discussion thereof is such an important part of maintaining wellness for men. It is the second most common cause of cancer deaths in men, and African American men are 1.7 times more likely to be diagnosed with prostate cancer than white men and 2.1 times more likely to die from it than their white counterparts. Health disparities exist, as Black men are less likely to receive treatment for prostate cancer than white men who even have a less advanced cancer.
Screening is as simple as making a preventive appointment with your primary care physician, discussing your family history with him or her, and having a PSA blood test performed. This test may be performed during an annual physical or wellness visit.
Shared decision-making between physician and patient is important to discuss your risk, your need for testing and next steps if your PSA level is elevated and concerning. Knowing your risk will save your life.
Prostate cancer is not a respecter of persons. It affects men of all socioeconomic backgrounds. It affects men from various cultures and creeds. It affects men of various geographical locales. Screening for it is relatively easy, and it begins with a question and conversation.
I know many personally who are near and dear to me who have the disease and who unfortunately died from complications of metastatic prostate cancer. I know many more who lived because they had the conversation and dared to move forward with appropriate screening at the appropriate age.
I am a Black man in a white coat, and I am having these same important conversations with male relatives, friends and neighbors, because for anyone to die from metastatic prostate cancer in this day and age would be a terrible tragedy on so many levels. I charge us all to undergo screening. I charge us all to embrace early detection. I charge us all, as Black men, to live.
Earl Stewart Jr., MD
Dr. Stewart graduated from Mercer University in 2005 and attended Meharry Medical College’s School of Medicine in Nashville, Tenn. He completed residency training in categorical internal medicine at the Warren Alpert Medical School of Brown University and its affiliated hospitals in Providence, R.I. Clinical interests are cardiovascular disease prevention, preventive medicine, spirituality in medicine, heart failure management in primary care, opioid addiction treatment, health disparities elimination, diversity in medicine and end-of-life care.