AUA 2022: Harm-to-Benefit of Three Decades of Prostate Cancer Screening in Black Men

(UroToday.com) In a podium presentation in the Late-Breaking Abstracts session at the 2022 American Urologic Association Annual Meeting held in New Orleans and virtually, Dr. Basourakos presented on the harm-to-benefit ration of prostate cancer screening in Black men over the past three decades. Prostate cancer screening, using serum prostate-specific antigen testing, has profoundly impacted the epidemiology of prostate cancer in the US, increasing the incidence and decreasing mortality. However, PSA-based prostate cancer screening is controversial given risks of overdiagnosis and overtreatment.

 There are persistent racial disparities in prostate cancer outcomes for Black men which warrant re-examination of the harms of screening relative to its cancer-specific mortality benefits in this population.

To do so, the authors estimated overdiagnosis and overtreatment for all races and Black men aged 50-84 years up until 2016, the most recent year with treatment data available, using both (a) excess incidence relative to 1986 based on the Surveillance, Epidemiology, and End Results (SEER) registry and US Census data and (b) an established microsimulation model of prostate cancer natural history. They further calculated numbers needed to diagnose (NND) and treat (NNT) to prevent one prostate cancer death by combining estimates with plausible mortality benefit.

Including men of all races, the authors estimated that between 1.5 and 1.9 million (range between estimation approaches) men were overdiagnosed and between 0.9 and 1.5 million men were overtreated for prostate cancer by 2016.

Examining both men of all races, and then Black men, analysis of the age-standardized prostate cancer incidence show evidence of substantial overdiagnosis in both groups. This effect was observed regardless of the estimation approach (excess incidence or microsimulation).

Over the same time period, the authors observed that prostate cancer mortality initially rose and then declined relative to 1986, with 270,000 fewer deaths among men of all races and 55,000 fewer deaths among Black men by 2016.

Based on the assumption that half of the 270,000 prostate cancer deaths avoided by 2016 were due to screening, the NND and NNT would be between 11 and 14 and 7 and 11 for men of all races, respectively.

Specifically, among Black men, the NND and NNT would be between 8 and 12 and 5 and 9 for Black men, respectively. When conservatively accounting for the lag between incidence and mortality, this numbers became even lower for Black men, with NNT reaching 1-2 or 2-3 in microsimulation models.

Thus, the authors conclude that this analysis suggests a more favourable harm-to-benefit trade-off for PSA-based prostate cancer screening than the USPSTF currently cites, particularly among Black men. These data constitute strong support for prostate-specific antigen screening, particularly in Black men, who are poorly represented in prostate cancer trials.