Like any plumber, James Lyles, 73, wanted to know what was going on beneath the surface. Two years ago, not long after he had a heart attack, his primary-care physician asked him whether he wanted to take a PSA test — a blood test for a “prostate-specific antigen” that helps physicians diagnose prostate cancer in its early stages.
Not seeing a downside, Lyles agreed — and the test showed he did have cancer. Now, in the middle of radiation treatments, he says he is feeling okay. In his view, a $25 blood test helped keep him alive.
“It only takes a vial of blood to tell you whether your health is in jeopardy or not,” he said. “It’s one of the easiest ways of finding out the truth about your body.”
Unintentionally, Lyles — a black man from Prince George’s County — had taken a side in a debate over prostate screening. A federally appointed task force said PSA tests for all men were unnecessary in 2012 before changing its mind last year and, in May, saying patients and their doctors should decide whether screening makes sense on a case-by-case basis.
African American men are more likely than white men to develop and die of prostate cancer, and there is an ongoing debate about when tests should be given to them.
For Navin C. Shah and Vladimir Ioffe, a urologist and a radiation oncologist in Prince George’s County, conversations among patients and doctors may not be enough when it comes to PSA screening. Sixty percent of their patients are African American, and they recommend that every black man older than 50 be screened, while the federal government’s task force recommends only that screening be discussed with patients.
“I think we are not doing justice to African Americans if we do not screen them,” Shah said. “It is a very sad story.”
Shah and Ioffe have data to support screening in a recently published paper for Urology Times. Looking at tissue from nearly 2,900 biopsies, they found that after the U.S. Preventive Services Task Force — the federally appointed panel that weighs in on the need for PSA tests — said routine PSA screening was unnecessary in 2012, fewer biopsies were performed. But more of those biopsies revealed cancer, suggesting that some cases are being diagnosed later than they could have been.
“Despite a reduction in the total number of prostate biopsies by 30 percent, there was a 100 percent increase in the total number of positive prostate biopsies,” the study says — because, as Ioffe put it, when “men are not being screened their cancer is progressing.”
“The main point of this whole thing is trying to advocate for high-risk men,” Ioffe said. “They need to be screened. Primary-care doctors shouldn’t be confused by the current recommendations.”
Discussing the need for PSA tests can set physicians against epidemiologists — or “number-crunchers,” as Ioffe called them. On one hand, prostate cancer doesn’t always kill. Testing every man could lead to a lot of unnecessary treatment — including invasive ones such as prostatectomy that can lead to side effects like incontinence or erectile dysfunction.
According to this interpretation, Shah and Ioffe’s finding that fewer biopsies are being conducted is a good sign, and that a higher proportion of biopsies show cancer means that healthy men aren’t getting unnecessary tests.
According to the National Institutes of Health, African American men have a 15 percent chance of getting prostate cancer compared with 10 percent of white men. Their chances of dying are also higher — 4 percent among black men compared with 2 percent among white men.
Last month, researchers at the University of California at San Francisco studying 10,000 African American prostate cancer patients found even those considered low-risk were twice as likely to die as patients from other demographics. The median age of black patients was also younger — 62 years old compared with 65 years old.
William Powell, 63, was a few years into his retirement from the Social Security Administration when he was diagnosed with prostate cancer in 2016.
“I almost had a mental breakdown,” he said. “It was scary. Really, really scary.”
Powell, one of Ioffe’s patients, called his diagnosis and subsequent radiation treatment “an education.” One out of four black men like him gets prostate cancer, he learned; many “don’t seek medical attention like they should.”
After his radiation treatment wrapped up last year, his PSA count is back to normal. Now, he is studying to become a minister and wants to use the pulpit to bring discussions about prostate cancer into the light. Right now, the disease is “kind of like a secret” in the black community, he said.
“People need to take this very seriously,” he said. “They really do. It will kill you.”
The U.S. Preventive Services Task Force guidelines, published in the Journal of the American Medical Association in May, say study of prostate cancer among black men should be a “national priority,” but the group was “not able to make a separate, specific recommendation on PSA-based screening.”
“Although it is possible that screening may offer greater benefits for African American men compared with the general population, currently no direct evidence demonstrates whether this is true,” the guidelines said.
Alex Krist, the task force’s vice chair, said doctors don’t yet know which men with high PSA levels are truly at risk of dying of prostate cancer. If all black men are screened, there will be false positives and overtreatment, and black men — already underrepresented in data that the recommendations are based on — will suffer the consequences.
“We need to be thinking about both the benefits and the harms,” he said. “Maybe it’s not right to screen all African Americans. . . . The task force has called out this evidence gap in searching out more.”
Ioffe called the guidelines “ambivalent and lukewarm.”
“It means that as far as the task force is concerned, you can either screen or not,” he said. “In contrast to this, we are saying that screening should be clearly recommended and endorsed for high risk men.”
Daniel J. George, an oncologist at Duke University who reviewed Shah and Ioffe’s paper, said worries about overtreatment were understandable. But he said the paper, while preliminary four years after the task force’s policy change, showed such concerns were “not a reason not to screen.”
“We may be diagnosing patients later in their disease course,” he said. “That’s the concern I would have with a less-aggressive cancer screening policy.”
Shah, meanwhile, said the task force recommendations weren’t enough. Everybody has a right to know their diagnosis, he said.
“Black people are suffering,” he said. “That’s a fact.”