Which Canadians Have Greater Need?

VANCOUVER, BRITISH COLUMBIA — Amid a lack of consensus on screening men for prostate cancer using the prostate-specific antigen (PSA), family physicians can consider suggesting that their Black and Indigenous patients undergo PSA testing for prostate cancer, according to a presentation at the Family Medicine Forum 2024.

Anmol Lamba, MD, an assistant professor of family medicine at The University of British Columbia in Vancouver, British Columbia, Canada, encouraged family physicians to stratify prostate cancer risk in their patient populations, taking race into account. Lamba is the co-program director of the enhanced skills program in the university’s family practice residency.

Lamba cited two recent Canadian analyses of race and prostate cancer outcomes. One prospective cohort study noted that Black Canadian men had similar prostate cancer outcomes compared with men of other races. But the former group is diagnosed with prostate cancer at a younger age and may benefit from earlier prostate cancer screening.

Another prospective cohort study that compared prostate cancer screening, diagnoses, management, and outcomes between Indigenous and non‐Indigenous men in Alberta concluded that “despite receiving care in a universal healthcare system, Indigenous men were less likely to receive PSA testing and more likely to be diagnosed with aggressive tumors and develop prostate cancer metastases than non-Indigenous men.” 

These studies point to a possible greater need for PSA testing in Black and Indigenous men in Canada, according to Lamba. They also suggest the need for systems that support equitable access to such healthcare, he added.

“Black, Indigenous, and other racialized patients with prostates may need earlier screening and universal screening,” said Lamba. “They tend to have a worse course with their prostate cancer, and it’s related to a complex web of issues, not just race.

“It’s not clear why certain populations have poor outcomes, but it likely isn’t because they are Black or Indigenous but [because of] all the other challenges to healthcare access and inequity they experience,” said Lamba.

Recommendations for Screening

The Canadian Task Force on Preventive Health Care’s current recommendations on screening for prostate cancer with the PSA test call for no screening in all men. This is a strong recommendation based on low quality evidence for men younger than 55 years and for men aged 70 years or older. It is a weak recommendation based on moderate quality evidence for men aged 55-69 years.

The Canadian Task Force is currently updating its prostate cancer screening guideline, according to Guylène Thériault, MD, a family physician and vice chair for the prostate cancer screening guideline with the Canadian Task Force on Preventive Health Care.

The current recommendation “is considered a weak recommendation, which means that shared decision-making should be part of the decision” about whether to screen, said Thériault. “In regard to the recommendation not to screen, if a patient would like to discuss prostate cancer screening, we have tools to foster shared decision-making with the patient. If thepatient, after having a discussion of the pros and cons of screening [with his physician], decides to be screened, then he will be screened. If he decides not to be screened, then he won’t be screened.”

The potential disadvantages of screening include false positives, which can lead to unnecessary biopsies of the prostate, and overdiagnosis or finding cancers that would never have become symptomatic. In the latter case, patients could be treated unnecessarily and develop complications such as urinary incontinence and erectile dysfunction, said Thériault. “These are things that people need to know,” but there may be an increased survival benefit in screening for some men, based on various factors.

For its part, the Canadian Urological Association suggests offering PSA screening to men with a life expectancy greater than 10 years. It states that the decision about whether to pursue PSA screening should be based on shared decision-making after the potential benefits and harms associated with screening have been discussed.

Lamba and Thériault reported having no relevant financial relationships.