Prostate-Specific Antigen Testing: Overview, Physiologic Characteristics of PSA, Other Prostate Cancer Markers

Black Men Should Get Prostate Cancer Screening In Their 40s

Black men should start getting tested for prostate cancer in their 40s, according to new guidelines.

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Black men should get an initial prostate cancer test between the ages of 40 and 45, according to new screening guidelines published by the Prostate Cancer Foundation.

In the U.S., Black men are at higher risk of being diagnosed with and dying from prostate cancer than men of other races. Data suggests that they are diagnosed with prostate cancer between three to nine years earlier than other men and are two times more likely to die from the disease than white men.

Guidelines for all men currently suggest getting an initial test for prostate cancer between the ages of 50 and 55, but according to the new guidelines, Black men should consider getting a test when they are between 40 and 45 years old.

"We don't know what causes prostate cancer," said Dr. William Oh, chief medical officer at the Prostate Cancer Foundation. "We know it is a disease of aging, we know that there are some environmental factors and we know that it tends to run in families. But, we don't currently know why Black men are higher-risk for being diagnosed with prostate cancer than other men," added Dr. Oh.

The guidelines were formed by an advisory board of physicians and patients and involved reviewing available evidence including trials and scientific studies to extract any relevant data on prostate cancer in Black men. This are not the first time it has been recommended that Black men get tested earlier, but as Dr. Oh explains, with other guidelines, this was often a footnote rather than the main aim of the work.

"We wanted to put these guidelines out there in a very clear and distinct way. So that the message was not lost in an asterisk and that it's basically as clear as possible for the population and the man and his family who are reading about these recommendations," said Dr. Oh.

Testing typically involves looking for levels of Prostate Serum Antigen. Although the consensus is that the test has saved many lives by detecting cancers early and enabling treatment, there is also some controversy around screening men who don't have any symptoms of prostate cancer.

"The PSA test is clearly the single best way to identify prostate cancer early, but it does have flaws," said Dr. Oh.

PSA testing can provide false-positive results, leading to invasive and costly testing for no reason. It also is unable to detect the difference between aggressive disease that may require urgent treatment and non-aggressive cancer, which may require no treatment at all or a "watch and wait" approach.

"There is a balancing act of identifying too many clinically insignificant cancers versus finding the ones that might be dangerous and even fatal if you find them too late," said Dr. Oh.

If implemented widely, the new guidelines could reduce deaths from prostate cancer in Black men by almost a third, according to the Prostate Cancer Foundation.

Prostate Cancer Screening

Men should go every year starting at about age 50, for a complete exam which should include a prostate exam, a urine check and a PSA blood test. If they're in a high-risk category, if they have a family history of prostate cancer, African-American, then those men should probably start at age 40 or 45 being seen on an annual basis.

Narrator

Why African-American?

Sheldon Marks, MD

We're not sure why African-American men have a higher rate of prostate cancer. The cancer they get tends to be more aggressive. It may be diet related, it may be genetic predisposition, it may be vitamin D related, because less sun getting through the skin because of the increased pigments, we're not really sure. But men who are at risk are African-American men and men with a family history of prostate cancer or even men who have a family history of breast or ovarian cancer in their mothers, grandmothers, sisters.

Narrator

So there's a connection between the mother's history of breast and ovarian cancer and their having prostate cancer?

Sheldon Marks, MD

Yes. It looks like these are all hormonally sensitive and hormonally driven cancers, and if a man's mother has ovarian or other hormonally sensitive cancers that he's probably at risk for prostate.

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Sheldon Marks, MD

Men should go every year starting at about age 50, for a complete exam which should include a prostate exam, a urine check and a PSA blood test. If they're in a high-risk category, if they have a family history of prostate cancer, African-American, then those men should probably start at age 40 or 45 being seen on an annual basis.

Narrator

Why African-American?

Sheldon Marks, MD

We're not sure why African-American men have a higher rate of prostate cancer. The cancer they get tends to be more aggressive. It may be diet related, it may be genetic predisposition, it may be vitamin D related, because less sun getting through the skin because of the increased pigments, we're not really sure. But men who are at risk are African-American men and men with a family history of prostate cancer or even men who have a family history of breast or ovarian cancer in their mothers, grandmothers, sisters.

Narrator

So there's a connection between the mother's history of breast and ovarian cancer and their having prostate cancer?

Sheldon Marks, MD

Yes. It looks like these are all hormonally sensitive and hormonally driven cancers, and if a man's mother has ovarian or other hormonally sensitive cancers that he's probably at risk for prostate.

Annual Breast Cancer Screening Beginning At 40 Saves Lives

Annual breast cancer screening beginning at age 40 and continuing to at least age 79 results in the highest reduction in mortality with minimal risks, according to a new study published today in Radiology, a journal of the Radiological Society of North America (RSNA).

Breast cancer is the second most common cause of cancer death for women in the U.S. Despite research demonstrating that consistent participation in screening mammography can reduce breast cancer deaths by 40%, only 50% or less of eligible women actually participate in annual screening.

"There is an ongoing debate over the recommendations for breast cancer screening, specifically about when to start and the frequency of screening," said lead researcher Debra L. Monticciolo, M.D., professor of radiology at Dartmouth Geisel School of Medicine in Hanover, New Hampshire.

Dr. Monticciolo said a recommendation by the U.S. Preventive Services Task Force (USPSTF) in 2009 to screen every other year, or biennially, beginning at age 50 resulted in a nationwide decline in screening participation. The USPSTF drafted new recommendations in 2023, suggesting women participate in biennial screening between 40 and 74. The American College of Radiology, the Society of Breast Imaging and the National Comprehensive Cancer Network recommend annual screening for women at average risk for breast cancer beginning at age 40 and continuing as long as the woman is in good health.

In the study, Dr. Monticciolo and colleagues performed a secondary analysis of Cancer Intervention and Surveillance Modeling Network (CISNET) 2023 median estimates of breast cancer screening outcomes. CISNET modeling data gives researchers the opportunity to estimate the outcomes of screening at various frequencies and starting ages using U.S. Data.

The researchers compared the benefits of screening, including mortality reduction, life years gained, breast cancer deaths averted, and its risks -- including benign, or unnecessary, biopsies and recall rates -- for four different scenarios: biennial screening of women 50-74 (the longstanding USPSTF recommendation), biennial screening of women 40-74 (the task force's new draft recommendation), annual screening 40-74, and annual screening 40-79. CISNET does not offer modeling past age 79.

The review of CISNET estimates showed that annual screening of women 40-79 with either digital mammography or tomosynthesis showed a mortality reduction of 41.7%. Biennial screening of women 50-74 and 40-74 showed mortality reduction of 25.4% and 30%, respectively. Annual screening of women 40-79 years showed the lowest per mammogram false-positive screens (6.5%) and benign biopsies (0.88%) compared to other screening scenarios.

"The biggest takeaway point of our study is that annual screening beginning at 40 and continuing to at least age 79 gives the highest mortality reduction, the most cancer deaths averted, and the most years of life gained," Dr. Monticciolo said. "There's a huge benefit to screening annually until at least 79 and even more benefit if women are screened past 79."

Dr. Monticciolo said that although the USPSTF uses CISNET modeling to formulate its recommendations, it refers to recall rates and benign biopsies as harms, rather than risks.

"To balance the harms and benefits of screening mammography, they're willing to give up some mortality benefit to avoid women being recalled for additional imaging and benign biopsies," she said.

According to the researchers' analyses, the chance of a woman having a benign biopsy following annual screening is less than 1%, and all recall rates for screening mammography are under 10%. When screening is performed annually with tomosynthesis, the recall rate decreases to 6.5%.

"The risks of screening are non-lethal and manageable for most women," she said. "But advanced breast cancer is often lethal. Breast cancer is easier to treat if it's found earlier; we're able to spare women extra surgeries and chemotherapy. It's just a better idea to shift to early detection, and that's what screening does."

Dr. Monticciolo said she hopes that her study will add to the body of literature that supports annual screening beginning at age 40 as the best way to diagnose cancer early.

"This paper is important because it shows once again that there's a tremendous increase in mortality benefit by screening annually between the ages of 40-79, and that the chances of experiencing harm are low on a per-exam basis," she said. "It comes down to valuing women's lives. I am hoping that primary care physicians see that risks of screening are manageable, and the benefits are tremendous. We need to do this for women."

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