(UroToday.com) The 2025 SESAUA annual meeting featured a prostate cancer session and a presentation by Dr. Mahdi Mottaghi discussing early longitudinal outcomes of black men undergoing PSA screening following implementation of a PSA-based risk stratification algorithm in a health system-wide initiative. The PSA test became widely available in 1987, which is a valuable screening tool but requires balancing the risks of overdiagnosis with detecting clinically significant prostate cancer. In 2012, the USPSTF gave a Grade D recommendation (against PSA screening for all men) for prostate cancer screening. The prostate cancer specific mortality rate declined between 1999 and 2011, but plateaued after 2012, however, the slope of the prostate cancer specific mortality decline was steeper before 2012 among Black men. In 2016, the Duke Cancer Institute, in collaboration with the Primary Care network, created a PSA-based screening algorithm for patient risk stratification, considering PSA, age, and race. In 2018, the USPSTF recommendations were escalated to a Grade C rating for prostate cancer screening, recommending patient-physician counseling. This study aimed to report the outcomes of PSA screening among Black men following implementation of the algorithm.
The patient cohort included Black men age 40-75 years with a serum PSA measurement following the initiation of an electronic health record (EHR) screening algorithm from February 2, 2017 through February 21, 2018. Duke's algorithm cut-points for PSA at ages 40-49, 50-69, and 70-75 years were ≥1.5, ≥3, and ≥6.5 ng/ml, respectively.
The clinical outcomes, including referral rate, biopsy, overall, and clinically significant prostate cancer diagnosis, were evaluated through February 2023. There were 5,914 Black men that underwent PSA screening within the first year of the algorithm implementation.
There were 480 Black men with sufficient follow-up included, with a total of 331 men (78%) referred to urologists. The median age, PSA, and positive family history were 57 versus 50 years (p = 0.01), 4.1 versus 3.0 ng/mL (p = 0.13), and 21% versus 9.6% (p = 0.001) for men referred versus non-referred men, respectively:
Of 122 (37%) men who underwent prostate biopsy, 83/122 (68%) were positive for prostate cancer (25% of the referred cohort), whereas clinically significant prostate cancer was detected in 59/122 (48%; 18% of the referred cohort). The most common management approach for the 83 men diagnosed with prostate cancer was radical prostatectomy (42.0%):
Black men with above-criteria repeated PSA levels had higher rates of mpMRI and biopsy, resulting in higher rates of prostate cancer and clinically significant prostate cancer compared to Black men with values below the cut-off:
Of 331 PCP-referred Black men, 73 (22%) had an mpMRI. Black men who underwent mpMRI, compared to those who did not, had comparable PSA (mean: 6.4 (SD 17.5) versus 5.7 (SD 3.2), p = 0.6), but significantly higher incidence of having a prostate cancer family history (30% versus 19%, p = 0.049), a prior biopsy(s) history (18% versus 5%, p < 0.001), and were more likely to be diagnosed with overall (47% versus 19%, p < 0.001) and clinically significant prostate cancer (30% versus 14%, p < 0.001). Compared to screening alone, the model using multiple variables (including PSA, repeat PSA exceeding cut-point criteria, prostate health index, and multiparametric MRI) had a higher diagnostic accuracy for prostate cancer detection (AUC 0.56 versus 0.93) and clinically significant prostate cancer detection (AUC 0.52 versus 0.75), respectively.
Dr. Mottaghi noted several limitations and opportunities based on the data from this study:
- The heterogeneous workup of patients (accepting the initial screen, repeat PSA, prostate health index, MRI, etc) limited the results
- The lack of White men as a control group is a limitation
- To date, data has not been compared to those men with a PSA below the threshold criteria
Dr. Mottaghi concluded his presentation by discussing early longitudinal outcomes of black men undergoing PSA screening following implementation of a PSA-based risk stratification algorithm in a health system-wide initiative with the following take-home points:
- Implementing a system-wide, structured EHR-based PSA screening algorithm among Black men facilitated the identification of prostate cancer across all age brackets
- A combination of PSA, family history, prostate health index, and mpMRI have demonstrated efficacy in enhancing cancer detection among this under-represented population
Presented by: Mahdi Mottaghi, Institute for Medical Research, Veteran Affairs Medical System, Durham, NC
Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Wellstar MCG Health, @zklaassen_md on Twitter during the American Urological Association (SESAUA) 2025 Annual Meeting, Nashville, TN, Wed, Mar 12 – Sat, Mar 15, 2025.