Prostate cancer causes more than twice the number of deaths in Chicago’s Black neighborhoods compared to white, and late diagnosis of the disease is a predominant factor. A new study being conducted at UI Health Mile Square Health Centers will determine whether a prostate specific antigen (PSA) screening procedure can eventually reduce this disparity while increasing the detection of life-threatening but treatable prostate cancer.
The University of Illinois Smart PSA protocol will provide primary care physicians with clear guidelines for recommending PSA screening based on age, established risk factors, and prior PSA level. The study will test the immediate impact of the protocol at seven Mile Square locations, a Federally Qualified Health Center (FQHC) network that serves a racially diverse group of Chicago neighborhoods. The information collected will provide researchers “a better understanding of whether and how Smart PSA screening can be disseminated in order to have a real impact on racial disparity,” said Peter Gann, MD, ScD, professor of pathology and director of the Translational Pathology Shared Resource at the University of Illinois Cancer Center and co-principal investigator of the study.
Nicole Gastala, MD, director of Behavioral Health and Addiction, UI Health Mile Square Centers and a member of the UI Cancer Center’s Cancer Prevention and Control program, serves as the other co-principal investigator. Jessica Richardson, MD, the physician lead at Mile Square’s main health center, will serve as clinical lead of the project.
“We believe that PSA screening can save lives while reducing overdiagnosis should testing be focused on the right men at the right time,” said Gann, who began his research on PSA screening while completing his doctoral thesis in the early 1990s. “Over the past few years empirical evidence has demonstrated that most deaths from prostate cancer occur among men ages 40 to 50 whose PSA levels are relatively high.”
Prostate-specific antigen, or PSA, is a protein produced by normal, as well as malignant, cells of the prostate gland. A PSA test, originally approved by the FDA in 1986 to monitor the progression of prostate cancer in men who had already been diagnosed with the disease, measures the level of the protein in a man’s blood, which is often elevated in men with prostate cancer. Eight years later, in 1994, the FDA approved the use of the PSA test in conjunction with a digital rectal exam (DRE) to test asymptomatic men for prostate cancer.
Primary care providers at Mile Square will be interviewed quarterly to measure their confidence in prostate cancer screening, and data will be compiled comparing the number of PSA tests ordered versus eligible men; PSA levels observed; demographics of the men screened; the number of patients referred for possible biopsy due to elevated PSA; biopsy results; and biopsy complications. The survey will record data provided by electronic health records, not directly from patients. A care coordination component of the study, led by nursing staff and patient navigators, will assist men with elevated PSA levels to ensure that they are able to successfully complete a referral to urology specialists at UI Health.
Other than skin cancer, prostate cancer is the most common cancer in American men. The American Cancer Society estimates that about 191,930 new cases will be diagnosed in 2020, with about 33,330 deaths culminating from the disease. Prostate cancer can be serious, but most men diagnosed with it do not die from it. More than 3.1 million men in the United States who have been diagnosed with prostate cancer at some point remain alive today.
Prostate cancer is more likely to develop in older men, in men with a family history of this cancer, and in Black men. About six cases in 10 are diagnosed in men who are age 65 or older, and it is rare in men under 40. The average age at diagnosis is about 66, according to the ACS.
The majority of patients diagnosed with prostate cancer at UIC are Black, with about 75% of the men identified at high-intermediate or advanced risk levels, Gann said. Nationally, the mortality rate for prostate cancer has declined substantially since 1990 for both Black and white men, but the racial disparity remains large, he said.
“This decline is attributed to a combined effect of earlier diagnosis through screening and more effective therapy,” Gann said. “Since the United States Preventive Service Task Force instituted new recommendations against all PSA screening in 2012, the rate of PSA testing has declined dramatically, and about equally in both Black and white populations.”
The Smart PSA screening strategy has four key elements, Gastala said: age to begin screening; how often to repeat the tests; what age to stop; and what PSA threshold should trigger a biopsy referral. All of the elements are selected with the goal of focusing screening on men at higher risk for clinically significant disease while minimizing testing of lower-risk men, for whom the benefit-risk balance is less favorable.
“An earlier start for high-risk men is supported by abundant evidence, including autopsy studies, indicating that Black men and those with a positive family history develop significant prostate cancer at earlier stages, and have a greater likelihood of having rapid progression to lethality,” Richardson said.
Age-specific data from the National Cancer Institute’s Surveillance Epidemiology End Results (SEER) program shows that Black men between the ages of 40 to 54 have prostate cancer incidence rates that are two to three times higher than whites.
The Smart PSA Study will be implemented at the seven Mile Square sites that provide adult primary care: Mile Square Health Center/UI Health, 1220 S. Wood St.; Englewood, 641 W. 63rd St., Chicago; Cicero, 4745-51 W. Cermak Road, Cicero; Back of the Yards, 4630 S. Bishop St., Chicago; South Shore, 7037 S. Stony Island Ave., Chicago; Humboldt Park, 3240 W. Division St., Chicago; and Rockford, 1221 E. State St., Rockford.
Assisting Gann, Gastala and Richardson are Michael Abern, MD; Ashish Ansal, MD; Vida Henderson, PhD, PharmD, MPH, MFA; Margaret Wright, PhD; and Karriem Watson, DHSc, MS, MPH, all of UIC. The lead research coordinator is Patrice King-Lee from the UI Cancer Center.