Disturbing Trends in Prostate Cancer in Recent Years

Fran Lowry

November 17, 2015

Prostate-specific antigen (PSA) screening for prostate cancer as well as the incidence of early-stage prostate cancer have declined substantially since the United States Preventive Services Task Force (USPSTF) recommended against such screening, conclude two new studies. Both were published November 17 in the Journal of the American Medical Association.

"The incidence of prostate cancer is dropping, but this doesn't mean that the cancer is not there, it just means we're not finding it," says David Penson, MD, MPH, from Vanderbilt University, Nashville, Tennessee. There is reason to be worried about the two trends reported in these studies, he writres in an accompanying editorial.

Data From Recent Years

The USPSTF made its first recommendation to curb PSA screening in 2008 in men aged 75 years and older.

Dr David Penson

In 2012, it broadened the recommendation to include all men, concluding that the benefits of PSA-based screening for prostate cancer did not outweigh the harms.

The first study, led by Ahmedin Jemal, DVM, PhD, from the American Cancer Society, Atlanta, Georgia, shows that PSA screening rates decreased by 18% between 2010 and 2013 among men aged 50 years and older and that the incidence of early-stage prostate cancer also declined in this age group, going from 498 per 100,000 men in 2011 to 416 per 100,000 men in 2012.

The second study, led by Jesse D. Sammon, DO, from Brigham and Women's Hospital, Boston, Massachusetts, found that although the 2008 USPSTF recommendations against PSA screening in men aged 75 years and older were not linked to changes in screening, the 2012 recommendations were more successful in decreasing screening, particularly in men younger than 75 years.

Dr Sammon, who is also with the Henry Ford Health System, in Detroit, Michigan, and his group found that in 2010, 23% of men aged 50 to 54 years underwent PSA screening, compared with 18% in 2013. A similar decline in PSA screening was seen in men aged 60 to 64, which went from 45% to 35%.

Has the Pendulum Swung Too Far?

In the editorial, Dr Penson acknowledges that physicians have been "overly aggressive" in prostate cancer screening and treatment over the past 20 years, but he notes "the pendulum may be swinging back the other way."

"The USPSTF recommendations have had a profound impact on the way we diagnose prostate cancer in the United States, and I'm not sure this is a good thing," Dr Penson told Medscape Medical News.

The incidence of prostate cancer is dropping, but this doesn't mean that the cancer is not there, it just means we're not finding it. Dr David Penson

"These studies show that primary care providers are taking the recommendations against screening to heart. The incidence of prostate cancer screening has dropped, and the incidence of prostate cancer is dropping, but this doesn't mean that the cancer is not there, it just means we're not finding it," he said.

"We have to rethink the way we approach the problem of diagnosing prostate cancer. Right now, it's an all-or-nothing approach," he said.

Urologists Are Getting the Message

"Urology has to take a look in the mirror," Dr Penson continued. "We've overscreened, and we've overdetected, and we've overtreated, but things are changing. Even before the USPSTF recommendations, we were starting to see a lot more active surveillance, and we were becoming more selective in who we screen. So we were very aggressive in one direction, and now the USPSTF has gotten very aggressive in the other direction. We have to meet somewhere in the middle. Too much screening is bad, but no screening is just as bad. We have to screen and treat smarter."

A good place to start is with screening men known to be at high risk, such as those with a strong family history of prostate cancer and African American men, Dr Penson said.

Also at high risk are men in their 40s who have high PSA levels. These men are at high risk of dying from prostate cancer, Dr Penson said.

"It may be possible to quantify baseline risk for high-risk prostate cancer. A study from Sweden found that a single PSA measurement of greater than 1.6 µg/L in men aged 45 to 49 years was associated with a 5.14% greater risk of dying of prostate cancer within 25 years of testing," he said. "Maybe the way to go is to have a single initial screening test at a certain age, and if the number is very low, screen infrequently or not at all, but if the number is higher, screen frequently, because that man is at higher risk for disease."

There Will Be Deaths

Stopping PSA screening altogether will avoid the impotence and incontinence and other adverse effects from the various treatments for prostate cancer, but it will come at a cost. More men will die from prostate cancer, Dr Penson said.

"In the European Randomized Study of Screening for Prostate Cancer, the investigators estimated that 27 prostate cancer cases were needed to be detected in the screening group to prevent one cancer death. Looking at the effect of the USPSTF recommendations, where Jemal et al estimate that around 33,000 fewer cases were detected in 2012, all you need to do is divide 33,000 by 27 and you see that roughly 1200 men who otherwise would have had their cancer detected and treated are not going to and are going to die of their disease. That's a 'back of the envelope' calculation and is obviously based on a lot of assumptions, but I am not sure it's entirely wrong," he said.

"There are costs on both sides of the equation, but we cannot take the extreme approach advocated by the USPSTF to stop screening in everyone," Dr Penson said.

It is a very simplistic way of dealing with a very difficult problem, pretending it's not there. Dr David Penson

"We know that about a third of the cases picked up on PSA screening would never have caused problems, so of those 33,000 cases that declined, 10,000 did not need to be picked up, but 23,000 did. We're not doing anyone any favors by simply burying our heads in the sand and pretending that this is not something to be worried about. It is a very simplistic way of dealing with a very difficult problem, pretending it's not there. To me, that's really worrying. I'm very disturbed by this," he said.

Even more worrying is the recent step by the Centers for Medicare and Medicaid Services (CMS), which is considering not only refusing to pay for prostate cancer screening because the USPSTF has designated such screening a category D but also penalizing physicians who do order PSA-based screening over a preset level, Dr Penson said.

"The CMS website is asking for comments. This is going to have a much bigger effect on primary care providers and urologists. They are going to look at providers' electronic medical records, and if they screen above a certain proportion of patients, they will be considered to be a poor-quality provider. Of course, physicians need to have a personal discussion with their patients about whether screening is the right thing to do, but this is going to kill that," he said.

Dr. Jemal’s study was supported by the American Cancer Society. Dr Jemal, Dr Sammon, and Dr Penson report no relevant financial relationships.

JAMA 2015;314:2054-2961, 2077-2079.


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