For two decades prostate cancer deaths had been steadily declining.
In 1993, about 39 in every 1,000 American men died from the cancer that starts in the walnut-sized gland between the bladder and the penis. Often that’s where the cancer stops; but in some men it progresses and can be life-threatening. With advances in treatment, though, the death toll was halved to under 20 per 1,000 by 2012.
But, “in 2013, we noticed that the slope or the speed with which this rate of prostate cancer mortality declined in the past, kind of changed,” says Dr. Serban Negoita, chief of the U.S. National Cancer Institute’s Data Quality, Analysis and Interpretation Branch. Negoita is the lead author of the prostate cancer section for the Annual Report to the Nation on the Status of Cancer released last month. That report found that “age-adjusted prostate cancer death rates leveled off … and were all around 19 per 100,000 for the most recent years captured,” he says. Rates still declined from 19.56 in 2012 to 19.26 in 2013, 19.1 in 2014 and 18.92 in 2015, but the decrease wasn’t statistically significant.
What’s more, even as the overall incidence of prostate cancer continues to decline, the rate of late-stage disease increased between 2010 and 2014, according to the Status of Cancer report. More men (about 8 per 100,000 based on the latest, 2014 figures, compared with around 6 in 100,000 in 2010) are being diagnosed with so-called distant cancer, or disease that’s spread from the prostate to other parts of the body like bone, lungs and brain.
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In the past screening for prostate cancer with a prostate-specific antigen, or PSA, test, was more roundly recommended and treatment essentially automatic following a cancer diagnosis. But in more recent years, evidence of harms associated with overdiagnosis or overtreatment has led to a more conservative approach. Experts note that because of the typically slow-growing nature of prostate cancer, more men die with the disease than from it, and they point out many men have been exposed to harms and side effects, like incontinence and impotence, of unnecessary treatment for prostate cancer. But as debate continues to swirl around prostate cancer screening, some experts have raised concerns that these latest trends show not enough is being done to protect men from this top cancer killer.
In regards to the potential benefits of screening, “there is still a huge question mark,” says Dr. Otis Brawley, chief medical and scientific officer for the American Cancer Society. “I think most of us tend to believe that there is a small benefit to prostate cancer screening. The clinical trials suggest for every 1,000 men screened over a period of time, instead of five dying from prostate cancer, four will die from prostate cancer. But a goodly number — several dozen — will be needlessly diagnosed and treated.”
Based on the latest evidence on screening, the U.S. Preventive Services Task Force recently changed its recommendation on prostate cancer screening to suggest, like the ACS and other groups do, that screening should be an individual decision made by a man in consultation with his physician. “We’re recommending that men age 55 to 69 who are considering prostate screening talk with their doctor about the benefits and harms of screening, and they decide whether screening is right for them,” says Dr. Alex Krist, vice-chairperson for the USPSTF, and a professor of family medicine and population health at Virginia Commonwealth University. That took the place of its controversial 2012 recommendation against men getting a PSA to screen for prostate cancer. The USPSTF still recommends against a PSA for men 70 and older.
“We made that change because we got more evidence and more follow up from the trials from 2012 to now,” Krist says. That provided a longer view of the impact of prostate cancer screening (and, where necessary, subsequent treatment) following detection. With longer follow-up from European research, “we observed that a few more men won’t die from prostate cancer — so it increased from 1.07 to 1.28 [per 1,000] — which doesn’t sound very big, and it’s not, but it gave us more confidence that over a great length of time more men might not die from prostate cancer.”
The Status of Cancer report notes that the use of PSA testing substantially decreased following the USPSTF recommendations against routine testing for men aged 75 and older in 2008 and for all ages in 2012; and it suggests this “may have contributed to the less rapid decline in prostate cancer death rates during the most recent years compared with the previous period.” But Negoita is careful to point out that the Status of Cancer report didn’t evaluate the reasons for the changing prostate cancer trends.
“When there was the change in 2012 from the U.S. [Preventive Services] Task Force to recommend against PSA screening, we saw screening numbers go down,” adds Karen Knudsen, enterprise director of the Sidney Kimmel Cancer Center at Jefferson, based in Philadelphia. “We also started to see more men present with advanced disease. And so while I cannot tell you for certain that these are related, certainly one followed the other.”
Others say it’s too early to tell if or how screening recommendations could have impacted prostate cancer deaths or late-stage disease rates. Krist emphasizes it’s not clear what’s driven the latest prostate cancer trends.
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Experts say a positive that’s come from more circumspection surrounding prostate cancer screening and treatment is that there seems to be more space in the conversation today for watchful waiting when a man is diagnosed with prostate cancer. That is to say there’s more dialogue around simply monitoring some prostate cancer closely — not necessarily treating it, where appropriate. “It used to be said that American men could never be persuaded to have no treatment for cancer — American men, they have a problem, they like to fix it,” says Dr. Anthony Zietman, a professor of radiation oncology at Harvard Medical School. “That was completely false. It was the physicians who couldn’t be persuaded to not treat men with cancer.”
But that’s changing, he and others say. “In 2012 most men with low-grade prostate cancers were getting surgeries or radiation — what we call active treatment — and that leads to more harms, like the incontinence or impotence,” Krist says. “Now about 40 percent of men — instead of just 10 percent — are getting what we call active surveillance, which might delay surgery or radiation, or even prevent it. And that can reduce the harms as well.”
Brawley says more than half of men diagnosed with localized prostate cancer — where the disease is only in the prostate when detected — are now being watched. “Most of those men will never be treated,” he says. “Watchful waiting is starting to catch on.”
That’s an important middle ground, clinicians say, as men try to cut through the noise that can make deciding what to do about the threat of prostate cancer a head-spinning affair. “I think in the past we were overaggressive in our screening. But screening wasn’t really the problem,” Zietman says. “It was treatment that was the problem. We were overaggressive in our treatment.”
To drill down further in making an individual decision, experts say it’s important to consider one’s family history. African-American men and guys with a first-degree relative (father, brother or son) who’s been diagnosed with prostate cancer before the age of 65 are considered to be at high risk of developing cancer; and they should talk with a health provider about the uncertainties, risk and potential benefits of screening starting at age 45, the ACS recommends. Those at even higher risk — with more than one first-degree relative who had prostate cancer — should begin that discussion at age 40. The ACS recommends men of average risk begin the conversation about prostate cancer screening at age 50.
If a man has a strong family history of not just prostate cancer, but breast cancer, ovarian cancer or pancreatic cancer, “we know that we should look very carefully at that particular man’s family for prostate cancer risk — and he may be a candidate for genetic screening,” Knudsen says. “Some of the same genetic alterations that give risk for breast, ovarian and pancreatic cancer also confer risk to prostate cancer.”
The USPSTF notes in their latest recommendation on prostate cancer screening that evidence is insufficient regarding whether “genetic or adjunctive imaging tests meaningfully changes the potential benefits and harms of screening. This is an important area of current research that has the potential to decrease the harms of PSA-based screening for prostate cancer.”
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A key is that men receive the information they need and aren’t made to feel like they should — or should not — get screened for prostate cancer, experts say. “A man who doesn’t want to be screened should not be criticized for that. And a man who does want to be screened should not be criticized for that. They should be supported in their decisions,” Brawley says. And if a man is diagnosed with prostate cancer, what he does next, including whether to treat it (and if so, how), shouldn’t be a forgone conclusion either. “It’s not about having prostate cancer, it’s do you have the kind of prostate cancer that needs treatment? So I think screening is OK so long as patients realize that if they are diagnosed with prostate cancer, that doesn’t inevitably mean treatment,” Zietman adds. “It means time to slow down and be thoughtful and make an informed decision.”
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