Prostate cancer incidence, screening have declined following USPSTF recommendations

Issue: December 25, 2015

The rates of PSA screening and early-stage prostate cancer incidence have declined since the 2012 U.S. Preventive Services Task Force recommendation to omit PSA screening from routine primary care, according to findings from two studies.

These trends are particularly apparent among younger men, data showed.

Otis Brawley

“I believe the data in our paper suggest that some doctors, and hopefully some patients, are starting to realize the true fact that the benefits of prostate cancer screening are still an uncertainty while the harms are well proven,” Otis Brawley, MD, FACP, chief medical officer of the American Cancer Society and a HemOnc Today Editorial Board member, told HemOnc Today. “I hope the data indicate men are making an informed choice as to whether to be screened and doctors are respecting that choice.”

Incidence data

Jesse D. Sammon, DO, urologist at Henry Ford Hospital’s Vattikuti Urology Institute in Detroit and a fellow at Brigham and Women’s Hospital, and colleagues examined 2000, 2005, 2010 and 2013 PSA screening data from 20,757 men who participated in the National Health Interview Survey to determine prevalence and determinants of screening prior to and following the U.S. Preventive Services Task Force’s (USPSTF) recommendations.

Results showed the prevalence of PSA screening was 34% (95% CI, 33-36) in 2000 and 2005. However, the prevalence decreased between 2010 (36%; 95% CI, 34-37) and 2013 (31%; 95% CI, 30-33). In a pooled analysis, 2013 was associated with lower odds of PSA screening compared with 2010 (OR = 0.79; 95% CI, 0.71-0.88).

However, declines only occurred among men aged younger than 75 years (OR = 0.78; 95% CI, 0.7-0.88) compared with men aged 75 years and older (OR = 0.85; 95% CI, 0.66-1.1).

Jesse D. Sammon

The largest screening declines occurred among men aged 50 to 54 years — dropping from 23% (95% CI, 20-26) to 18% (95% CI, 15-21; OR = 0.71; 95% CI, 0.56-0.91) — and men aged 60 to 64 years, dropping from 45% (95% CI, 41-49) to 35% (95% CI, 32-39; OR = 0.69; 95% CI, 0.54-0.89).

Less screening may lead to men being diagnosed with more advanced, less treatable prostate cancer, Sammon told HemOnc Today.

“There’s very good evidence to consider PSA screening in men aged 55 to 69 years,” Sammon said. “We are screening men aged older than 75 years too much. But this recommendation affects younger men who could benefit from early detection. I think we are likely to see more diagnosis of higher-risk disease that may be less amenable to cure, and we may be putting more men at greater risk for prostate cancer.”

It will be crucial to continue follow-up of the effect of the USPSTF recommendation, Sammon added.

“We should look further at targeting research to those at high risk — African American men and men with a family history of prostate cancer — to see the effects of these recommendations,” Sammon said.

Prostate cancer diagnoses

In a second study — published simultaneously in JAMA — Brawley and colleagues evaluated age-standardized prostate cancer incidence by stage from 2005 through 2012 using data culled from 18 population-based SEER registries. Researchers also evaluated PSA screening rates among men aged 50 years or older without a history of prostate cancer who responded to the National Health Interview Survey in 2005, 2008, 2010 and 2013.

Results showed prostate cancer incidence among men aged at least 50 years was 534.9 per 100,000 men in 2005 and 540.8 per 100,000 men in 2008. These rates then declined in 2010 (505 per 100,000 men) and 2012 (416.2 per 100,000 men). The largest decrease occurred between 2011 (498.3; 99% CI, 492.8-503.9) and 2012 (416.2; 99% CI, 411.2-421.2).

In raw numbers, the number of men diagnosed in the U.S. with prostate cancer declined from 213,562 in 2011 to 180,043 in 2012.

Similar declining rates were identified when stratifying patients by race and region.

The percentage of men who reported a PSA screening within the previous 12 months dropped over time, starting at 36.9% in 2005 and increasing to 40.6% in 2008 before falling to 37.8% in 2010 and 30.8% in 2013.

In relative terms, screening rates increased 10% (RR= 1.1; 99% CI, 1.01-1.21) between 2005 and 2008 and then decreased 18% (RR = 0.82; 99% CI, 0.75-0.89) from 2010 to 2013. Results appeared comparable in analyses stratified by age (50-74 years vs. 75 years and older).

“I believe there is a legitimate place and use of screening, but it was overused and men were harmed,” Brawley said. “Too much unproven benefit was promised. Men were told that screening and aggressive treatment saves lives. They were not told this was unproven theory and 1.1 million American men were unnecessarily treated over a 20-year period.”

Limitations exist to PSA screening, Brawley added.

“One special limitation is it finds a lot of disease that does not need therapy,” he said. “Ironically, the data to prove that PSA screening finds over-diagnosed cancer is far better than the data to show it saves lives. I hope men who choose to be screened are informed they may be diagnosed with a cancer in which the recommendation is to watch it. There are some men with aggressive disease where the legitimate recommendation is therapy, but the effectiveness of those therapies are not as clear as once thought.”

Personalized screening

A more individualized strategy — rather than an “all-or-none” approach — may be an appropriate guide to prostate cancer screening, David F. Penson, MD, MPH, director of the center for surgical quality and outcomes research and chair of the department of urologic surgery at Vanderbilt University Medical Center, wrote in an editorial that accompanied both studies.

“There is reason to be concerned about the decline in prostate cancer screening and prostate cancer incidence reported by Sammon et al and Jemal et al,” Penson wrote. “Certainly, physicians have been overly aggressive in their approach to prostate cancer screening and treatment during the past 2 decades. But the pendulum may be swinging back the other way.”

These data may indicate personalized screening strategies that are tailored to a man’s individual risk and preferences are warranted at this time, Penson added.

“By doing this, it should be possible to reach some consensus around this vexing problem and ultimately help men by stopping the swinging pendulum somewhere in the middle,” he wrote. – by Anthony SanFilippo

For more information:

Otis Brawley, MD, FACP, can be reached at American Cancer Society, 250 Williams St., Atlanta, GA 30303; email: otis.brawley@cancer.org.

Jesse D. Sammon, DO, can be reached at Brigham and Women’s Hospital, 45 Francis St., Boston, MA 02115; email: jsammon@partners.org.

References:

Jemal A, et al. JAMA. 2015;doi:10.1001/jama.2015.14905.

Penson DF. JAMA. 2015;doi:10.1001/jama.2015.13775.

Sammon JD, et al. JAMA. 2015;doi:10.1001/jama.2015.7273.

Disclosure: The researchers and Penson report no relevant financial disclosures.