Prostate cancer screening in the United States remains uneven, even among men who face clearly higher risks. A new analysis shows that many high-risk patients do not receive recommended PSA tests, despite long-recognized risk factors.
Researchers reviewed records from 176,326 men aged 40 or older who visited primary care clinics between 2020 and 2022. They used prostate-specific antigen testing as the measure of screening. Each patient received a risk score based on known prostate cancer risk factors. The team then used statistical models to study how these scores related to screening and cancer diagnosis.
Who Gets Screened—and Who Doesn’t
Only 31.4% of men received a PSA test. Screening rates rose as risk increased. Among men with a risk score of 4, 78.1% were tested. The model confirmed a strong link between higher risk scores and higher odds of screening.
Insurance type also influenced testing. Men with Medicaid or commercial insurance were more likely to receive a PSA test than those with Medicare. Self-pay patients were less likely to be screened. Former smokers and never smokers were screened more often than current smokers.
Older age, African American race, and family history increased the likelihood of testing. But the study found that African American men and low-income patients were still screened less often than their elevated risk would suggest. The authors report that these gaps point to ongoing inequities in primary care.
Risk Scores, Testing Odds, and Diagnosis
Prostate cancer diagnoses also rose as risk increased. In men with a risk score of 5, one in four received a prostate cancer diagnosis. In deeper analysis, older age, African American race, family history, and even the appearance of the word “prostate” in clinical notes strongly predicted cancer detection. This pattern suggests that clinician focus on prostate health influences both testing behavior and diagnosis.
What the Findings Mean
The study shows that screening for prostate cancer in high-risk men is still not meeting clinical expectations. Even though screening becomes more likely at higher risk levels, African American and low-income men continue to face lower screening rates than expected. The authors call for better clinician education and stronger decision-support tools. They argue that these steps could help primary care practices follow risk-based guidelines, reduce missed chances for early detection, and improve equity in prostate cancer outcomes.
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