Risk-stratified PSA screening needed to halt ‘rapid rise’ in distant-stage prostate cancer
Key takeaways:
- Incidence of distant-stage prostate cancer in California increased from 2011 to 2021.
- Prostate cancer mortality, which had declined for decades, plateaued after 2012.
An analysis of prostate cancer trends in California revealed an unexpected spike in distant-stage disease cases between 2011 and 2021.
Meanwhile, prostate cancer mortality — which had been on the decline for decades — plateaued after 2012.
“We expected to see an increase in the incidence of advanced prostate cancer. ... However, we were surprised by the magnitude,” Erin L. Van Blarigan, ScD, associate professor of epidemiology and biostatistics, as well as urology, at University of California, San Francisco, told Healio.
American Cancer Society statistics have shown incidence of distant-stage prostate cancer has been increasing across the country. More research is needed to determine the reasons for this trend, including social or geographic factors that could be contributing.
Van Blarigan and colleagues conducted a cohort study to examine trends in prostate cancer incidence and mortality rates in California by stage, age, race and ethnicity, and region.
Investigators used SEER program and U.S. Census data to analyze incidence. They used data from the California Cancer Registry and California Department of Public Health’s Center for Health Statistics to analyze mortality trends.
The calculation of delay-adjusted incidence rates and mortality rates served as a main outcome, with investigators calculating annual percentage changes (APC).
The analysis revealed 387,636 prostate cancer cases and 58,754 prostate cancer deaths statewide between 2004 and 2021.
Most cases (61.5%) occurred among non-Hispanic white men. About half (52.4%) occurred among men aged 55 to 69 years, and 39.7% occurred among men aged 70 years or older.
Incidence of distant prostate cancer increased by 6.7% (95% CI, 6.2%-7.3%) per year on average between 2011 and 2021.
Sub-analysis by race and ethnicity showed APCs of 6.5% (95% CI, 4.2%-13.4%) between 2011 and 2021 for men who identified as Asian American, Native Hawaiian or Pacific Islander, as well as an APC of 8% (95% CI, 6.9%-9.5%) between 2014 and 2021 for men who identified as Hispanic.
Incidence of distant prostate cancer increased by approximately 6% or more per year in nine of 10 regions in the state.
Prostate cancer mortality rates declined by 2.6% per year between 2004 and 2012, but they then plateaued from 2012 to 2021 (APC, 0.1%; 95% CI, 0.6% to 1.6%). The plateau in mortality persisted across ages, races and ethnicities, and regions.
Researchers acknowledged study limitations, including an inability to examine trends for distinct ethnic groups, limited statewide data regarding race information for men who identify as American Indian and Alaska Native, and a lack of data on patients’ disease stage at time of diagnosis.
“Efforts to develop and implement evidence-based risk-stratified PSA screening are urgently needed to stop the rapid rise in distant-stage prostate cancer and prevent the anticipated subsequent rise in prostate cancer mortality,” researchers wrote.
Men should be encouraged to talk with their physicians about whether a PSA test is appropriate, Van Blarigan added.
“The current guidelines are to make personalized screening decisions by talking to your health care team. Knowing your PSA value is the first step,” Van Blarigan told Healio. “Based on multiple factors like the PSA level, age, race and family history, additional testing may be warranted to identify men who would benefit from more workup (eg, secondary testing of blood/urine, prostate MRI, prostate biopsy, etc.).
“Research is needed to improve our prostate cancer screening strategies so that we catch aggressive prostate cancer at early stages when it can be treated, without overdiagnosing tumors that would never cause a problem,” she added. “Additionally, certain regions of California had higher incidence of advanced disease and high mortality, including the North Coast, San Diego-Imperial and Inland Empire. Research to improve implementation of screening and treatment of prostate cancer in those regions is particularly important.”
For more information:
Erin L. Van Blarigan, ScD, can be contacted at erin.vanblarigan@ucsf.edu.
Perspective
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Prostate cancer is the second-leading cause of cancer-related death among men in the U.S., yet a substantial number of men diagnosed with prostate cancer will not die of the disease — even without treatment. Willet Whitmore, MD, encapsulated this dilemma more than 5 decades ago in his presidential address to the American Urological Association with the now-legendary quote: “For a patient with prostate cancer, if treatment for cure is necessary, is it possible? If possible, is it necessary?”
The answers to these questions have since been provided by randomized trials such as The ERSPC trial and PROTECT. ERSPC demonstrated a nearly 30% reduction in prostate cancer mortality over 21 years among men randomly assigned to PSA screening, while the PROTECT trial — in which 77% of participants had low-risk disease — showed no significant difference in prostate cancer mortality at 15 years between the observation group and treatment group.
Unfortunately, this crucial information was not fully available when the U.S. Preventive Services Task Force (USPSTF) recommended against routine PSA screening in 2010. The impact of that recommendation is evident in the findings of this study, which show a decline in prostate cancer diagnoses, followed by an increase in distant metastatic disease, as well as a plateau in the decline of prostate cancer mortality across various geographic and racial groups in California. Since 2018, the USPSTF has revised its stance, recommending shared decision-making about PSA screening for men aged 55 to 69 years based on earlier reports of the trends observed in this paper.
The hesitancy surrounding prostate cancer screening is understandable. Elevated PSA levels commonly result from numerous benign conditions, and prostate biopsy carries risks such as discomfort, bleeding and sepsis. Moreover, overtreatment of prostate cancer remains a significant concern. However, the harms of screening can be mitigated by the use of urinary and/or blood-based biomarkers, with or without MRI, to better select men who should proceed to prostate biopsy. Advances in genomic testing and emerging AI technologies also are improving our ability to identify men who are suitable for active surveillance.
As these approaches continue to evolve, it is hoped that future follow-up to this study will demonstrate reductions in both metastatic disease and prostate cancer mortality, as well as a decrease in the incidence of prostate cancer diagnoses — particularly through a reduction in invasive testing for men with low-risk disease.
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