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

The adoption of prostate-specific antigen (PSA) screening in the United States beginning around 1987 has profoundly changed the epidemiology of prostate cancer, with a rapid doubling of incidence and, by 2015, a 50% decrease in annual prostate cancer mortality. Randomized trial data support a significant mortality benefit to PSA screening. However, uncertainty remains regarding how much PSA screening (as opposed to advances in the therapeutic armamentarium) is responsible for declining mortality rates as well as how the benefits of screening measure up to the harms of finding and treating cancers that never would have caused morbidity or mortality (i.e., overdiagnosis and overtreatment). This uncertainty is even greater for Black men, who have historically been underrepresented diagnostic and therapeutic clinical trials despite having nearly double the risk of prostate cancer death compared with the general population. This difference in mortality is one of the largest racial disparities in any cancer.