US prostate cancer incidence, screening rates down by about 16 percent in 2012

Two papers just published in the Journal of the American Medical Association provide the best documentation yet of a significant decline in PSA testing for risk of prostate cancer. This decline certainly appears to be a direct consequence of the grade D recommendation of the U.S. Preventive Services Task Force (USPSTF) in early 2012.

The two papers are by Jemal et al. (on behalf of the American Cancer Society) and by Sammon et al. An editorial by Penson appears in the same issue of JAMA. A commentary summarizing and commenting on much of the content of the two articles and the editorial has already been reported on the National Public Radio web site.

Jemal et al. used  data from the Surveillance, Epidemiology, and End Results (SEER) registries and from the National Health Interview Surveys (NHIS). They report that:

  • Prostate cancer incidence per 100,000 in men 50 years and older (N = 446,009 in the 18 SEER areas) was 534.9 in 2005, 540.8 in 2008, 505.0 in 2010, and 416.2 in 2012.
  • Incidence rates started to decline in 2008, with the largest decrease occurring between 2011 (498.3/100,000) and 2012 (416.2,100,000) — a 16.5 percent decrease in incidence.
  • The number of men 50 years and older diagnosed with prostate cancer nationwide declined by 33,519, from 213,562 men in 2011 to 180,043 men in 2012 — a 15.7 percent decrease.
  • In relative terms, there was a 10 percent increase in the screening rate between 2005 and 2008 and then an 18 percent decrease between 2010 and 2013.
  • Similar screening patterns were found in age subgroups from 50 to 74 years and 75 years and older.

Jemal et al.  conclude that:

Both the incidence of early-stage prostate cancer and rates of PSA screening have declined and coincide with 2012 USPSTF recommendation to omit PSA screening from routine primary care for men. Longer follow-up is needed to see whether these decreases are associated with trends in mortality.

Sammon et al. conducted a very similar analysis and came to very closely analogous conclusions in their research letter (which can be read in full on the JAMA web site. They found that PSA screening rates dropped dropped by 16 percent — from 36 to 30 percent of men — during the same period.

These data will be very disturbing to many. However, the supporters of the USPSTF may actually feel that this reflects “success” in adherence to their recommendation about screening for prostate cancer. The truth is that we really won’t know until about a decade from now, when we may or may not start to see a return to the levels of de novo diagnosis of men with metastatic prostate cancer that were evident in the late 1980s — before the initiation of widespread PSA testing for risk of prostate cancer.

Unfortunately the full text of the editorial by Penson is not available on line. However, it is clear from tghe article on the NPR web site that Dr. Penson is very disturbed by this trend.

It also has to be said that the comment by Dr. Brawley (the chief medical officer of the American Cancer Society), who is quoted in the NPR web site, is interestingly difficult to interpret. He is said to have said that:

I think it’s a good thing if doctors and men are having a discussion so that the patient can truly make an informed decision.  I think its a bad thing if the doctors are making a decision and not discussing it with the patient at all.

There is probably some truth to that statement, but whether it is the whole truth is rather more difficult to know.


3 Responses

  1. “I think its a bad thing if the doctors are making a decision and not discussing it with the patient at all.”

    That is extremely easy to interpret in one case. For example, doctors who decided to screen their patients without telling them (easily done when there are blood samples taken for other tests at the same time) were doing a very bad thing.

  2. A new article on the Medscape web site today also addresses this topic.

  3. I really appreciate your posting about these papers. I got copies of all of them, courtesy of our local medical library. I was especially impressed with Dr. Penson’s editorial.

    In particular, he did a nice job of indicating that non-screening results in increased mortality. In essence, he took the figure “27 additional cases needed to be detected (NND) in the screening group to prevent 1 prostate cancer death” (ERSPC, 13-year update — median of about 6 years from diagnosis for the screening group) and applied it to the projected decrease of 33,519 cases detected in 2012 per the above studies, yielding an estimated 1,241 (33,519/27) additional deaths in the US from prostate cancer stemming from the impact of the Task Force recommendation. While that figure involves some substantial assumptions, it does suggest an eye-catching consequence of the Task Force’s recommendation against screening. Dr. Penson quite appropriately goes on to note that this might be a conservative estimate, as longer follow-up will likely substantially reduce the number of detections needed to save a life, based on the trend of the three ERSPC major reports and related studies such as the Goteborg contingent of the ERSPC, and such reduction would multiply the death toll resulting from non-screening.

    I mentioned his calculation in comments to the Task Force on its plan to review research on screening. I also recommended adding an arm to the Task Force’s Analytic Framework diagram for “non-screening,” including harms such as mortality, loss of years of life, morbidity, later detection of BPH, later detection of prostatitis, and added cost. (Somewhat off topic, I recommended splitting the screening arm into two: one for “informed screening,” and one for “uninformed screening.” (My diagram has just about triple the blocks and more than triple the arrows as in the original Task Force diagram — a true work of art!)

    Dr. Penson also mentioned individualizing PSA screening intervals, which many of us support.

    It was gratifying to see a major journal feature such papers and thoughts, especially as it is widely read in the primary care community, which appears to be the main constituency of the US Preventive Services Task Force.

    Thanks again!

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