New advanced cases of the disease are increasing even as the overall prevalence drops.
There is a puzzling, contradictory and alarming prostate cancer statistic causing concern in the healthcare community. In 2008 and 2012, the U.S. Preventive Services Task Force (USPSTF) recommended a reduction in prostate-specific antigen (PSA) screenings, a move that has happily coincided with a reduction in overall prostate cancer cases in this country.
But here’s the new rub: The incidence of newly diagnosed prostate cancers that are advanced, metastatic and harder to successfully treat appears to have increased, especially among the higher-risk age group of men age 55-69. And it’s not just a small bump up. The increase is significant.
A new study, “Increasing incidence of metastatic prostate cancer in the United States (2004-2013),” published in advance online in July by Prostate Cancer and Prostatic Diseases, examined data drawn from the National Cancer Data Base (NCDB) between 2004 and 2013, which included information from 1,089 U.S. healthcare facilities.1 The investigators found that while the incidence of diagnosed low-risk prostate cancer had decreased between the years 2007 and 2013 to 37% less than was reported in 2004, the annual incidence of metastatic prostate cancer increased more than 72% than was found at diagnosis in 2004.
One of the study authors, Edward M. Schaeffer, MD, Department of Urology, Northeastern University Feinberg School of Medicine, Chicago, said the higher acuity of disease among new patients caught his attention. “As a urologist who actively treats men with prostate cancer, I wanted to understand who these men were in more detail so that we could potentially understand why they presented with the more aggressive disease than the other 97% of men who present with localized disease,” he told ADVANCE. “So, we initiated the study to review the ‘landscape’ of prostate cancer in the U.S. today. The National Cancer Data Base collects information nationwide on approximately 70% of all new invasive cancer diagnoses. In particular, I was interested in those men entering NCDB hospitals with metastatic prostate cancer at initial presentation.”
The reason underlying the greater number of men presenting at diagnosis with metastatic prostate cancer is still open to some speculation. “We do not know why this is occurring,” said Schaeffer. “It could be that the population is aging; it could be that the population of patients at the NCDB hospitals is changing; it could be that there is better imaging to detect metastatic disease in these men; it could be that there are shifts in lifestyles (obesity, smoking) that have affected cancer; or it could be that the disease itself has changed and become more aggressive.”
The study results have raised a precautionary red flag for Ben Lowentritt, MD, director of the Prostate Cancer Program at Chesapeake Urology, Owings Mill, Maryland, who is concerned that the guidelines calling for a reduction in the number of screenings may have adversely affected a high-risk segment of men who eventually present with advanced prostate cancer.
“The goal of any cancer screening is to find cancer at earlier stages when it is more likely to be cured and less likely to have already spread. By limiting PSA screening, we miss that opportunity to catch patients earlier and we are seeing more patients whose cancer has already spread,” he cautioned. “The American Urological Association (AUA) continues to recommend screening for all men between 55 and 70, and for all men who are at higher risk for disease (African-Americans, men with a family history of prostate cancer) starting at age 50 or earlier. Many men who continue to be healthy into their 70s still have more than 10-year life expectancies and should also consider continuing screening after discussing it with their doctor. Many of our patients continue to ask their primary care providers to have a PSA checked, and each individual continues to be their own best advocate.”
Schaeffer, too, said individuals must weigh all the evidence when considering the best screening schedule. “I think patients need to be vigilant about their own healthcare. I believe, as outlined in the AUA and [American College of Surgeons] web pages, that prostate cancer screening is a shared decision-making process. If a patient’s healthcare provider has not begun this discussion with him, he should – as an informed patient – bring it up with the provider.”
Lowentritt would prefer a more aggressive screening schedule to handle what may be a more aggressive disease. “A core component of population health management is an appropriate use of screening techniques. The trends we are seeing towards more aggressive disease will only be further complicated if we continue down the path of eliminating the use of PSA to screen for prostate cancer,” he cautioned. “This is terrible for patients and bad for our attempts to control healthcare costs. Treating advanced, metastatic cancers is far more disruptive to patient productivity and quality of life, and it is also far more expensive.”
He also takes issue with the dates of the data that informed this latest study. “Evaluating PSA screening based on how prostate cancer was diagnosed and treated in 1992-2000 (the timing of most of the studies the USPSTF based their recommendations on) is not valid because of how much our evaluation and treatment paradigms have changed in the intervening years,” Lowentritt stated. “Active surveillance, robotic surgery and improved radiation and hormonal regimens have all had the effect of lessening the dreaded complications of prostate cancer treatment that are seen as the major quality-of-life detractors. We also work hard to determine who are the right patients to biopsy, so we are not necessarily biopsying everyone we may have 10, 15 or 20 years ago. Our evaluation and treatment have evolved (and continue to evolve) just as they do for all diseases and all specialties. Burying our head in the sand and pretending this disease does not exist is not the right way to handle things.”
The study investigators do not disagree with an eyes-wide-open philosophy. Indeed they concluded, “Beginning in 2007, the incidence of metastatic prostate cancer has increased especially among men in the age group thought most likely to benefit from definitive treatment for prostate cancer. These data highlight the continued need for nationwide refinements in prostate cancer screening and treatment.”
1. Weiner AB, et al. Increasing incidence of metastatic prostate cancer in the United States (2004-2013). Prostate Cancer and Prostatic Diseases advance online publication 19 July 2016.