For decades, one of oncology’s most glaring disparities has been hiding in plain sight. Black men in the United States die from prostate cancer at more than twice the rate of white men – a gap that accounts for over half the total Black-white gap in deaths from cancer. Yet, clinical guidelines have largely ignored this stark reality. 

The Challenge: When “Average Risk” Isn’t Average

The story begins with a troubling trend. Following a 2012 recommendation from the United States Preventive Services Task Force that advised against routine PSA screening, testing rates plummeted – but not equally. Black men, who were already less likely to be screened, experienced the steepest declines. By 2019, advanced-stage prostate cancer diagnoses were rising 4.5% annually, with Black men disproportionately affected. 

Aggregate data on PSA screening, advanced-stage diagnosis, and mortality were masking the disproportionate impact on Black men because population-wide recommendations failed to account for dramatically different baseline risks. Further, while the major screening trials collectively included more than 746,000 participants, only 0.45% were Black men, creating a critical evidentiary bias that has shaped clinical practice guidelines. 

The Investigation: Uncovering Hidden Disparities

Across multiple institutions, striking patterns were revealed: 

Perhaps most revealing: when Black veterans received annual PSA screening, their cancer-specific mortality rates matched those of screened white veterans. The disparity wasn’t biological – it was a disparity in care. 

The Solution: Race-Conscious Guidelines

In 2023, the American Urological Association broke new ground by explicitly recommending earlier screening (age 40-45) for men of African ancestry. The guideline emphasized shared decision-making while recognizing systemic barriers to holding conversations about PSA screening. Research showed Black men were less likely to receive information about PSA screening, with only 29% of primary care physicians routinely discussing their increased risk.

Implementation: Bridging the Communication Gap

Recognizing that guidelines alone don’t change practice, the team developed targeted implementation strategies, including an infographic facilitating patient-provider conversations about screening and clear messaging that baseline PSA levels, not race alone, drive personalized screening decisions.

The Outcome: A Model for Equity-Driven Guidelines

This work demonstrates that removing race from clinical algorithms isn’t always the answer. Sometimes, achieving equity requires explicitly acknowledging how racism and social factors create differential disease burden. The key is ensuring that race-conscious approaches reduce rather than perpetuate disparities.

Call to Action for Specialty Societies

This case study offers crucial lessons for guideline developers across specialties. True equity requires more than removing bias. Rather, it demands actively working to close gaps in care. As the Encoding Equity Alliance continues its mission, AUA’s prostate cancer screening work stands as a beacon, showing how thoughtful, evidence-based approaches can transform disparities from inevitable statistics into solvable problems.