Does Complexity and Racialization Limit PSA Screening?

Prostate cancer racial disparities are perhaps the most pronounced in all oncology. These disparities exist along the prostate cancer care continuum, from screening, diagnosis, and treatment to outcomes. Many outcome disparities, such as mortality and advanced disease at presentation, are thought to be linked upstream to disparities in screening. Based on populational data, the 5-year cancer-specific survival rate for men diagnosed with localized prostate cancer approaches 100%. ¹ However, prostate cancer remains one of the leading causes of cancer deaths among men, with Black men more than 2 times as likely to succumb to the disease compared with other men. ¹ While the overall number of men who die from prostate cancer has decreased since the implementation of prostate-specific antigen (PSA) screening, the disparity in mortality persists. ² In this essay, we explore how variation in guideline recommendations among various medical organizations and the resulting choice overload may reduce screening and contribute to racial disparities and how health care may reduce this variation.

Multiple societies have developed prostate cancer screening guidelines, and the recommendations vary widely, leaving physicians and patients confused. After the U.S. Preventive Services Task Force (USPSTF) changed its recommendations in 2012 to not perform PSA screening, PSA screening rates naturally decreased, yet the number of men presenting with advanced disease has increased. ³ In 2018, the USPSTF reversed its position and recommended prostate cancer screening at age 55 in conjunction with shared decision-making. ⁴ Still, the different organizations that publish prostate screening guidelines vary in the starting age for screening, which ranges from 45 to 55 for a man of average risk. ^{5 –7} Adding further complexity, these organizations also recommend different ages to start screening Black men compared with other men (Table 1).

This complexity in the recommended age to start screening for prostate cancer may reduce screening rates if patients and physicians are unsure when testing is needed. Commonly, when faced with multiple choices, people either fail to decide or make a suboptimal decision. This scenario or end result comes by way of a concept called choice overload. Choice overload occurs when we have too many options to choose from, fatiguing the brain and impairing our ability to make an optimal decision and to be satisfied with that decision. ⁸ Choice overload is further exacerbated by changing the screening age for Black men. For example, the recommendation assumes that the Black population is a homogenous group. Furthermore, because physicians do not often ask patients to self-identify their race, physicians have more complexity in deciding what race to classify patients.

Though we do not know the quantitative impact that choice complexity has on screening, by way of varying screening guidelines, the literature describing how choice complexity degrades decision-making is robust. ⁸ In national efforts to use a checklist to reduce central line–associated bloodstream infection, one major contributor to increase the use of the Centers for Disease Control and Prevention guideline was to condense the 150-page guideline of nearly 100 recommended interventions to a 5-item checklist. ⁹

All organizations developing prostate cancer screening recommendations use the same base data to make their recommendations. Because there are uncertainties in the evidence, organizations make their best recommendations, which come with random errors. Each organization seeks to optimize its part, yet in doing so, they risk compromising the whole and potentially reducing screening rates. Health care lacks an entity empowered to reduce variation among guidelines, although the National Academy of Medicine or the Agency for Healthcare Research and Quality could fill this role. This issue of complex choices, resulting from variation among guidelines exists in many areas of medicine, such as cardiovascular disease, renal disease, and other cancers.

To better understand the extent to which choice overload impacts screening, the Department of Health and Human Services should support research to evaluate whether convening the guideline developers to agree on a single age to initiate PSA testing increases screening rates and reduces disparities in screening. For example, a potential way forward would be to have a consensus across all medical organizations that men without a family history or inherited germline mutation and with >10 years of life expectancy, undergo PSA screening starting at the age of 50 years. Public health organizations, professional societies, and health systems could then educate physicians that screening is beneficial and straightforward and build screening decision rules into the electronic medical record. This approach would likely be far more impactful than debating the age to start screening for White, Black, and other races of men.

In conclusion, we suggest that choice complexity caused by variation among organizations regarding what age to start prostate screening may reduce screening rates. Importantly, this decrease in screening could be the reason for the increased number of men being diagnosed with advanced disease. Research is needed to evaluate whether reduced choice complexity can increase screening rates and reduce inequities in prostate cancer screening.