If a person has risk factors associated with an increased risk of developing prostate cancer (including Black race, germline mutations, strong family history of prostate cancer), in particular if they have an increased risk of metastatic disease, an earlier age to begin screening may be appropriate in addition to a shorter re-screening interval.42 Black individuals have a disproportionate cancer burden and a two-fold higher risk of death from prostate cancer compared to White individuals.43 A study using three models discovered that patients who self-identify as Black appear to have earlier age of onset and increased risk of metastases before clinical diagnosis.44 This study found the risk of a Black patient developing fatal prostate cancer, if not diagnosed, reached the same level as that of the general population three to nine years earlier, informing the proposal that Black patients initiate screening approximately five to ten years prior to the recommendation for average-risk individuals.44 This increased risk may be addressed by screening Black patients more frequently (e.g., annually), but the risk of overdiagnosis among older Black patients is considerably higher than the average-risk population, making SDM and personalized screening particularly important. Empirical studies have shown patients with germline BRCA1 and BRCA2 variants have increased risks of both disease onset and progression.45 The IMPACT study revealed a high positive predictive value (PPV) of PSA screening (with biopsy referral threshold 3 ng/mL) in these patients and a high frequency of clinically significant cancers,46 particularly among BRCA2 carriers.47 The IMPACT study showed a stronger relationship (eight-fold increased risk) between BRCA2 carriers and aggressive cancer for whom systematic PSA screening is indicated, while further study is needed to determine the role of screening among BRCA1 mutation carriers.47 Similarly, mutations in ATM, MLH1, MSH2, MSH6, PMS2, HOXB13, NBS1, and CHEK2 need further study. In the IMPACT study, after one screening round, carriers of pathogenic variants in mismatch-repair genes MSH2 and MSH6 had a higher risk of prostate cancer compared with age-matched non-carrier controls, potentially supporting screening of these patients.45 These patients may benefit from both earlier initiation of PSA screening and shorter intervals between screenings. Although there is no standard definition of strong family history, several Guideline and consensus statements propose common criteria that include: 1) people with one brother or father or two or more male relatives with one of the following: a) diagnosed with prostate cancer at age < 60 years; b) any of whom died of prostate cancer; c) any of whom had metastatic prostate cancer. 2) family history of other cancers with two or more cancers in hereditary breast and ovarian cancer syndrome or Lynch syndrome spectrum.48, 49 Studies have consistently found elevated risk of prostate cancer in patients with a family history of prostate cancer50-53 and also in patients with a family history of prostate and breast cancer.54, 55 In some studies, the observed increase in risk may be partly due to detection bias associated with greater compliance to screening and biopsy51 among patients with a known family history. Some studies have differentiated low- and high-risk prostate cancers associated with family history52, 53 and have suggested focusing on the association between family history and high-risk cancer as more relevant for making screening recommendations. Patients with a strong family history (e.g., two or more first-degree relatives have a four-fold relative risk compared to those without a family history50) should ideally be genotyped to ascertain whether this is associated with a pathogenic variant (e.g., BRCA1/2, Lynch Syndrome, ATM, CHEK2) or one or more of a growing set of identified germline DNA damage-repair mutations found in patients with metastatic prostate cancer diagnoses.56 In the absence of this information, patients with a strong family history may be screened earlier and/or more frequently, similar to those with detected germline pathogenic variants. Again, SDM is highly recommended given the uncertainty involved in the PSA screening setting.