Imagine facing a life-threatening illness that could have been caught earlier with a simple test, but you weren't offered that test because of your race. That's the harsh reality many Black men face with prostate cancer. The question is, should we be proactively screening Black men for this disease?
Junior Hemans' story is a stark reminder of this issue. In 2014, at age 51, he requested a prostate-specific antigen (PSA) test during a routine check-up, knowing Black men are at higher risk. The test, which isn't routinely offered, revealed he had elevated PSA levels. "[The diagnosis] was a shock... because I had no symptoms," he recounts. The PSA test helps detect conditions like prostate cancer or an enlarged prostate.
Hemans, now successfully treated, is a strong advocate for a national screening program targeting men at the highest risk. "Imagine if, back to when I was 51, there was a screening programme already in place [before my diagnosis], I could have been diagnosed earlier," he says. "A screening programme saves more of the man, and gives us a better and cheaper means of saving that man." He also pointed out that while he was aware of his risk, many other Black men aren't.
Prostate cancer has surpassed breast cancer as the most diagnosed cancer in England, with over 55,000 new cases annually. One in eight men will be diagnosed in their lifetime. But here's the crucial difference: Black men face a significantly higher risk – one in four. Despite these alarming statistics, there's no national screening program in place.
The UK National Screening Committee (NSC) is deciding whether to recommend an NHS screening program for prostate cancer, potentially targeting high-risk groups like Black men. Keith Morgan, Associate Director of Black Health Equity at Prostate Cancer UK, emphasizes the strong evidence supporting targeted screening for Black men, citing their increased risk of late-stage diagnosis and higher mortality rates.
"And this can’t simply be put down to where they live," Morgan explains. "Our latest report shows that, even in the least deprived areas, Black men die from prostate cancer at higher rates than white men in the most deprived areas. Leaving screening to chance entrenches these inequalities and feeds a fatal postcode lottery." He believes the evidence is compelling enough for the NSC to recommend targeted screening for Black men. While other groups, like those with a family history, might also benefit, the case is strongest for Black men. Prostate Cancer UK has vowed to challenge the government if the NSC disagrees, demanding a clear plan to address late diagnosis and inequities.
Morgan further argues, "What is clear is that we can’t simply leave it to chance for Black men. If the NSC decides we aren’t ready for screening, the government must act swiftly to fund serious awareness-raising and change outdated guidelines so GPs can proactively talk to Black men about their risk and the choice to have a PSA blood test."
David James, Director of Patient Projects and Influencing at Prostate Cancer Research, agrees, stating there's "sufficient evidence" to demonstrate the benefits of a screening program, starting with the highest-risk groups: Black men aged 45 to 69, men with relevant family history, and those with certain genetic mutations.
"We think that what we’ve demonstrated is that such a screening programme is cost effective and in fact delivers a positive socioeconomic benefit to the country as a whole, and that it won’t overwhelm the NHS. We’re very hopeful that the National Screening Committee and the government will decide in favour of a screening programme."
But here's where it gets controversial... Not everyone agrees that a targeted screening program is the right approach. Some researchers and academics are concerned about potential over-diagnosis, arguing for more evidence.
Naser Turabi, Director of Evidence and Implementation at Cancer Research UK, believes the evidence on targeted screening is still "very unclear." He points out that the increased risk in Black men is likely a mix of environmental and genetic factors. He notes, "Although they have a higher incidence of prostate cancer, the PSA test [is] used to detect prostate specific antigen and black men have a higher natural level of PSA, which could lead to over-diagnosis among black men." In other words, a higher PSA level doesn't always mean cancer, and could lead to unnecessary anxiety and treatment.
Turabi also raises concerns about grouping all Black men together, given the wide variation within the group. "I think another issue is that black itself is a social category, which is different from thinking about ancestry," he says. "It’s possible, and there are some indications that this is true, that some of the genetic risks for people of African ancestry are applied to a subset of what we would describe as black men... One of the challenges here is that we don’t have as much genomic data regarding black men, people of African ancestry, as we do the general population." This lack of data makes it harder to accurately assess risk.
Professor Rhian Gabe of Queen Mary University of London echoes this concern. "I don’t think there’s a huge amount of evidence for black men because, unfortunately, I don’t think we’ve got enough research that includes black men in it. And that’s something we’re trying to address." She co-leads the Transform trial, a £42m screening trial by Prostate Cancer UK, aiming to find the best screening methods. Significantly, one in ten participants will be Black men, a much larger sample size than previous studies.
"That’s why we’re aiming to get a high number of black men in our study, because we really need that evidence and we really want to give them the opportunity to participate in our research," she adds.
Harveer Dev, an academic urologist at the Early Cancer Institute, University of Cambridge, believes that societal feeling towards this subject is important. "I think, societal feeling towards this subject needs to be taken into account, if not entirely dictating the decision, at least in part," Dev added.
So, what do you think? Should there be a national screening program for prostate cancer that specifically targets Black men, given their higher risk? Or are the concerns about over-diagnosis and the lack of comprehensive data too significant to ignore? Should other high risk groups be prioritized as well? What other factors should the NSC consider when making their decision? Share your thoughts in the comments below.
