In contrast, the USPSTF found insufficient evidence to confidently determine whether the benefits of screening outweighed the harms. In 2009, the European Rando- mised Study of Screening for Prostate Cancer (ERSPC; ISRCTN49127736) showed that PSA screening was associ- ated with a small absolute reduction in prostate cancer mortality and a high risk of overdiagnosis.8 Subsequently, the AUA and the ACS advised that eligible men have the opportunity to make decisions on the basis of an understanding of the potential benefits, risks, and uncer- tainties associated with screening.3,4 In 2012, however, the USPSTF recommended against any screening, arguing that the many potential harms of screening outweighed a survival benefit that was categorized as small to none.7 Six years later, the USPSTF changed its recommendation to Grade C — individualized decision-making for men 55 to 69 years of age.6 This was on the basis of more recent evi- dence from the ERSPC trial showing that screening reduced both prostate cancer mortality and the risk of metastatic disease and from data showing increasing uptake of active surveillance among men with low-risk prostate cancers, which could mitigate the harms of over- diagnosis and overtreatment. However, the USPSTF con- cluded that randomized trial evidence was inadequate to recommend earlier screening for Black men. Although randomized trials are the gold standard for eval- uating screening programs, findings may not be widely generalizable because study cohorts are highly selected, often with truncated age ranges and limited racial and eth- nic diversity. In recommending earlier screening for Black men, the AUA and the ACS considered both clinical trial and epidemiologic data.3,4 In this issue of NEJM Evidence, Garraway et al.,9 under the sponsorship of the Prostate Cancer Foundation (https://www.pcf.org/), present the results of a systematic literature review on the benefits and risks of beginning PSA screening of Black men before 50 years of age. On the basis of relevant evidence from observational and modeling studies, they offer a set of guidelines to address disparities by recommending PSA screening with optional or reflex DREs for Black men beginning at 40 to 45 years of age after shared decision- making with their health care practitioners. The USPSTF is currently revising its prostate cancer screening guideline and thus, will have the opportunity to address the dispari- ties faced by Black men; I hope they also take modeling studies into consideration when they do so.10 There is a precedent for this. The most recent USPSTF lung cancer screening guideline lowered the starting age and the smoking history eligibility requirements largely on the basis of modeling data.11 The revised criteria addressed disparities created by the initial guideline, which dispro- portionately excluded groups at high risk for lung cancer, including Black adults and younger women. The USPSTF, AUA, and ACS guidelines and now, the Prostate Cancer Foundation are all currently aligned in recommending that eligible men be offered screening within the framework of shared decision-making. This is important because persons considering screening should understand when recommendations go beyond clinical trial data. Offering Black men the opportunity to make informed decisions at an earlier age makes sense. This strategy may help address important health disparities while respecting patient autonomy. Disclosures Author disclosures are available at evidence.nejm.org. Author Affiliation 1 University of Iowa Carver College of Medicine, Iowa City References 1. National Cancer Institute, Surveillance, Epidemiology, and End Results Program. Cancer Statistics Explorer Network, SEER*Ex- plorer. Prostate. April 19, 2023 (https://seer.cancer.gov/statistics- network/explorer/). 2. Nyame YA, Gulati R, Heijnsdijk EAM, et al. The impact of intensi- fying prostate cancer screening in black men: a model-based analy- sis. J Natl Cancer Inst 2021;113:1336-1342. DOI: 10.1093/jnci/ djab072. 3. Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA guideline. J Urol 2013;190:419-426. DOI: 10.1016/j. juro.2013.04.119. 4. Wolf AMD, Wender RC, Etzioni RB, et al. American Cancer Society guideline for the early detection of prostate cancer: update 2010. CA Cancer J Clin 2010;60:70-98. DOI: 10.3322/caac.20066. 5. Qian Z, Al Khatib K, Chen X, et al. Investigating the racial gap in prostate cancer screening with prostate-specific antigen among younger men from 2012 to 2020. JNCI Cancer Spectr 2023;7: pkad003. DOI: 10.1093/jncics/pkad003. 6. Grossman DC, Curry SJ, Owens DK, et al. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation state- ment. JAMA 2018;319:1901-1913. DOI: 10.1001/jama.2018.3710. 7. Moyer VA. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012;157: 120-134. DOI: 10.7326/0003-4819-157-2-201207170-00459. NEJM EVIDENCE 2 For personal use only. No other uses without permission. Copyright © 2024 Massachusetts Medical Society. NEJM Evidence is produced by NEJM Group, a division of the Massachusetts Medical Society. Downloaded from evidence.nejm.org by WILLIAM OH on April 23, 2024. For personal use only. No other uses without permission. Copyright © 2024 Massachusetts Medical Society. All rights reserved.
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