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University of Illinois Cancer Center researchers, working with the Mile Square Health Center, recently completed the "Smart PSA" study, the first trial of prostate cancer screening guidelines specifically adapted for high-risk communities with majority Black patient populations. The results were published in the American Cancer Society journal Cancer. Mile Square, a Federally Qualified Health Center with a network of clinics, is a unique part of UI Health, the academic health system at the University of Illinois Chicago (UIC), which includes the Cancer Center.

In a 15-month-long intervention, primary care providers (PCPs) were encouraged to adopt guidelines that tailored screening with blood levels of prostate-specific antigen (PSA) based on age, race, family history, and prior PSA level. Patients with elevated PSA were referred to the urology service at UI Health for potential biopsy.

PSA screening in the general population has been controversial for decades, since excessive screening can lead to overdiagnosis and unnecessary treatment of men with non-threatening tumors. The U.S. Preventive Services Task Force, which discouraged all such screening in the past, now supports individualized screening decisions but offers no guidelines for high-risk men.

Meanwhile, in neighborhoods served by Mile Square clinics with predominantly Black residents, death from prostate cancer is 2 to 3 times higher than the national rate, and Black men tend to develop aggressive prostate cancer at a younger age. Many PCPs, lacking screening guidelines that address risk, were uncertain about how or whether to implement early detection.

The study reports that during the intervention screening increased by 76% over a matched historical period, with the largest increase among Black men ages 40 to 49. The detection of cancer at biopsy jumped from 43% to 74%, and the incidence of cancer with aggressive features surprisingly increased five-fold over the control period, with no perceptible increase in low-grade tumors.

The study was led by Peter Gann, MD, ScD, Department of Pathology at the College of Medicine, who stated: "The trial demonstrated two main things: first, that PCPs practicing in high-risk communities can adopt and sustain risk-adapted prostate cancer screening, and second, that intensified screening in this context produces an excess of potentially lethal cancers due to the large pool of occult cancer, the relatively sparse exposure of this high-risk population to prior screening, and the slow rate at which prostate cancers tend to progress. We predict that if intensified screening is sustained, the balance will shift towards more non-threatening cancers, which would require adjusting the guidelines to focus even more on avoiding unnecessary diagnoses - a better problem to have."

UIC co-authors on the study were: Nathan Stackhouse, MD, MPH; Nicole Gastala, MD; Weiwei Ma, PhD, MS; Margaret E. Wright, PhD; Karriem Watson, DHSc, MS, MPH; Christopher Stepping, MEd; Patrice King-Lee, MS; Ziqiao Xu, MS; Tushar Patel, MD; and Michael Abern, MD (currently at Duke University).