AUA Posters Highlight Racial Gaps in PSA Screening, Prostate Cancer Risk

During a podium session at the American Urological Association (AUA) 2024 Annual Meeting, 3 speakers focused on prostate-specific antigen (PSA) testing, which can indicate prostate cancer in men with higher PSA levels.

Jonathan Ryan, a third-year medical student at Nova Southeastern University Dr Kiran C. Patel College of Allopathic Medicine, presented on PSA testing rates and disparities among nearly 100,000 men in the All of Us database.¹ The study included White, Black, Hispanic, and Asian men aged 40 years and older. To ensure a focused analysis, those with a history of prostatitis, hematuria, urinary retention, or prior prostate cancer diagnosis before their first PSA measurement were excluded from this study.

Despite the large cohort, the researchers found that less than 19% of men in the database had received PSA testing. A significant proportion of those tested were White men (75%), followed by Black (15%), Hispanic (8%), and Asian (2%) men.

The study also showed that White men were being screened at older ages, contrary to AUA guidelines. By race, the median age at first screening was 53 for Black and Asian men, 54 for Hispanic men, and 58 for White men. Despite starting PSA screening at a younger age, Black (12.1%), Hispanic (11.8%), and Asian (13.1%) men were less likely to undergo PSA testing compared with their White counterparts (22.2%).

The largest gap based on age was seen in the proportion of men being screened at age 70 and older, of which 89% were White, followed far behind by Black (5%), Hispanic (4%) and Asian (2%) men. Men who were first screened at an older age were also more likely to have at least a college education (85% vs 79%) and be homeowners (77% vs 67%) compared with all patients with a PSA screening.

PSA test | Image credt: angellodeco – stock.adobe.com

During the podium session, Adam S. Kibel, MD, chair of urology at Brigham and Women’s Hospital and professor of surgery at Harvard University School of Medicine, said this may be reflexive, and that minority patients who believe they’re at higher risk of prostate cancer may be getting screened on the younger end of AUA guidelines.

Multivariate logistic regression showed that race, age, income, education, insurance type, and home ownership status all remained significant predictors of who received PSA screening.

“This suggests that minorities are being screened earlier per guidelines but disproportionately affected by PSA screening disparities, and the incidence of PCa [prostate cancer] in Black men may be further underestimated,” Ryan said.

A different study on midlife baseline (MB) PSA testing also found racial disparities in predicting lethal prostate cancer.² Presented by Giuseppe Chiarelli, MD, research fellow at Humanitas, this study focused on White and Black men aged 40-59 years who underwent MB PSA testing between 1995 and 2019. The researchers categorized patients into 4 age groups and analyzed the impact of MB PSA levels on predicting lethal prostate cancer using multivariable Fine-Gray regression.

Their analysis, which included data from more than 112,000 men, revealed striking racial disparities in the incidence of prostate cancer and its severity. White men were more likely to have their first PSA test at age 50 to 54 years (33.9%), while Black men tended to undergo testing in the youngest age group at 40 to 44 years (27.6%). Additionally, Black men had a significantly higher rate of prostate cancer diagnosis (7.0% in Black patients vs. 3.9%) and lethal prostate cancer (1.2% vs 0.6%) compared with White men (both P < .0001).

When comparing the risk of lethal prostate cancer based on MB PSA levels, the study found that Black men faced almost double the risk of developing lethal prostate cancer compared with White men within the same age category and with similar MB PSA levels. According to the authors, this highlights the importance of considering separate and different cutoffs for MB PSA when guiding prostate cancer screening in clinical practice, particularly to address the heightened risk faced by Black men.

Finally, a study presented by Giuseppe Cirulli, MD, research fellow at Vattikuti Urology Institute delved into the potential of free PSA percentage (%fPSA) in predicting the future risk of developing prostate cancer.³ %fPSA is a marker recommended by AUA guidelines for guiding biopsy decisions in cases of mildly elevated PSA levels, but it has not been explicitly considered as a tool for future PSA screening. This study sought to address this gap by examining its potential role in predicting prostate cancer incidence in a contemporary North American population.

The research focused on men aged 40 to 59 years who underwent %fPSA testing between 1995 and 2019, resulting in a cohort of 1308 patients. Using established methodology, %fPSA levels were categorized into three groups: less than 10%, 10% to 25%, and greater 25%. The main outcome of interest was the incidence of prostate cancer, with cumulative incidence curves used to illustrate the risk of developing prostate cancer over time based on %fPSA categories. Multivariable Fine-Gray regression was employed to assess the role of %fPSA as a predictor of future prostate cancer development after adjusting for potential confounders.

Patients in this study were mostly aged 55 to 59 years (33.4%), had a Charlson comorbidity indexof 0 (67.1%), were White (75.6%), and had a %fPSA between 10% and 25% (68.8%). The median (IQR) follow-up was 2.9 (0.9-5.1) years, and during this time, 228 (17.4%) patients developed prostate cancer.

At 5 years, patients with %fPSA less than 10% had the highest risk of developing prostate cancer (22.8%), followed by those with %fPSA 10% to 25% (8.9%) and greater than 25% (3.1%; P < .001). These findings revealed that men with %fPSA less than 10% had a significant 6.21-fold increased risk of developing prostate cancer compared with those with %fPSA greater than 25%.

This study marks the first comprehensive examination of %fPSA in the context of PSA screening, according to the authors. The results underscore the practical utility of %fPSA in enhancing PSA screening strategies in clinical practice, allowing for more targeted screening approaches where individuals at the highest risk of developing prostate cancer can receive intensified screening efforts.

References

1. Ryan J, Jin W, Yu H, Mahal B, Punnen S. Exploring PSA testing rates and screening disparities in the All of Us dataset. Presented at: AUA 2024 Annual Meeting; May 3, 2024. https://www.auajournals.org/doi/10.1097/01.JU.0001008716.22569.77.01
2. Chiarelli G, Matthew D, Stephens A, et al. Midlife baseline PSA as a predictor of lethal prostate cancer: racial differences between Black and White men. Presented at: AUA 2024 Annual Meeting; May 3, 2024. https://www.auajournals.org/doi/10.1097/01.JU.0001008716.22569.77.02
3. Cirulli GO, Chiarelli G, Finati M, et al. Testing free PSA percentage as a tool in predicting future risk of developing prostate cancer: a system wide analysis of a contemporary North American cohort. Presented at: AUA 2024 Annual Meeting; May 3, 2024. https://www.auajournals.org/doi/10.1097/01.JU.0001008716.22569.77.03