A rise in the incidence of metastatic prostate cancer from 2004 to 2013

A newly published article in the journal Prostate Cancer and Prostatic Diseases suggests that there has been a relative 72 percent rise in the incidence of metastatic prostate cancer from 2004 to 2013 — mostly among men of 55 to 69 years of age.

There has long been concern among many in the prostate cancer community that a decreasing emphasis on the value of screening for risk of prostate cancer would lead to a rise in the incidence of metastatic disease. It would be easy, therefore, to place all the blame for this apparent rise in the increase in risk for metastatic disease on the U.S. Preventive Services Task Force (USPSTF). However, to be fair to the USPSTF, their initial recommendation that most men should not be being screened for risk of prostate cancer was not issued — even in draft form — until very late in 2010. The final D recommendation wasn’t issued until 2012. Thus, the increase in risk for metastatic disease since 2004 can’t really be blamed on the USPSTF.

The paper by Weiner et al. actually looks at data from the National Cancer Database (NCDB) over the period 2004 to 2103, and shows the following:

  • The NCDB contained data on 767,550 men diagnosed with prostate cancer between 2004 and 3013.
  • Of these 767,550 men
    • 32 percent were diagnosed with low-risk, localized disease
    • 45 percent were diagnosed with intermediate-risk, localized disease
    • 20 percent were diagnosed with high-risk, localized disease
    • 3 percent were diagnosed with metastatic disease
  • The annual incidence of low-risk prostate cancer was 37.36 percent in 2004, 33.15 percent in 2008, and 23.96 percent in 2013 (a relative 37 percent decrease in incidence from 2004 to 2013).
  • The annual incidence of intermediate-risk prostate cancer was 39.74 percent in 2004, 45.46 percent in 2008, and 50.06 percent in 2013 (a relative 26 percent increase in incidence from 2004 to 2013).
  • The annual incidence of high-risk prostate cancer was 20.45 percent in 2004, 19.07 percent in 2008, and 21.44 percent in 2013 (a relative 5 percent increase in incidence from 2004 to 2013)
  • The annual incidence of metastatic prostate cancer was 2.45 percent in 2004, 2.33 percent in 2008, and 4.30 percent in 2013 (a relative 72 percent increase in incidence from 2004 to 2013).
  • The greatest increase in metastatic prostate cancer was seen in men aged 55 to 69 years (a 92 percent increase from 2004 to 2013).

Weiner et al. also note that:

These findings cannot be explained completely by reactions to the USPSTF recommendations alone, as increases in metastatic prostate cancer began in the years before its release.

The data in the NCDB reflect data from > 1,000 healthcare facilities in the USA from 2004 to 2013. To that extent, it is likely that the trends seen in the NCDB reflect national trends in the incidence of different types of prostate cancer. What is less clear is why such trends may be occurring. Over the time frame of the entire study the numbers of men being diagnosed with any type of prostate cancer rose steadily from 68,814 in 2004 to 88,460 in 2008; fell back down to 74,902 in 2009; rose again to 83,451 in 2011; and had fallen back down to 67,070 by 2013.

We need to be cautious about over-reaction to data like these. Clearly we would prefer to see stability in the numbers of men being diagnosed with low-risk prostate cancer and a steady decline in the numbers of men being diagnosed with metastatic disease. However, small changes from year to year in exactly how prostate cancer is diagnosed can have huge ramifications. By 2013 we were able to diagnose metastatic prostate cancer with sensitive forms of imaging that were not available in 2004. This change in diagnostic capability alone may be responsible for at least part of the increase in likelihood of a diagnosis with metastatic prostate cancer.

An article in the Philadelphia Inquirer this morning also covers this paper. The article contains quotes from many relevant individuals, including the current chair of the USPSTF and Dr. Otis Brawley of the American Cancer Society (among others).

Editorial comment: Our thanks to one of our correspondents for bringing this new paper to our early attention.

2 Responses

  1. For an impressive response to this paper join twitter and follow #urojc for an international urology discussion of these issues. Some of the top uros everywhere weigh in. This also happens several times a year with other urology publications.

  2. Suspect USPSTF May Be a Major Culprit in a Broader Sense, but Timing is Puzzling Regarding the Specific Findings

    Thank you for publishing your review and comments on this extremely important paper! I knew I could count on finding the key facts to fill in the blanks and get the links at this site. I’ll just take this moment to express how grateful I am for your long commitment and highly effective work that informs us about developments. (I first saw the news yesterday evening on Lester Holt’s NBC Nightly News report (http://www.aol.com/article/2016/07/20/cases-of-aggressive-prostate-cancer-on-the-rise-research-finds/21435427/ .)

    As you suggested, the timing in the surge of metastatic cases at diagnosis does not seem to match the timing of changes in USPSTF recommendations. We can focus on this key finding, reported above, for analyzing whether the USPSTF shares much of the blame for the increase in detection of metastatic prostate cancer at diagnosis, the kind that is too often lethal – especially if widely spread to locations distant from the prostate: “The annual incidence of metastatic prostate cancer was 2.45 percent in 2004, 2.33 percent in 2008, and 4.30 percent in 2013 (a relative 72 percent increase in incidence from 2004 to 2013).” We see that the percentage of such metastatic diagnoses were relatively stable between 2004 and 2008, based on annual data for just those two years. Between 2008 to 2003 there was a surge of 85%, a near doubling (2.33/4.30 = 1.85). What the USPSTF was doing was not encouraging screening during the entire period from 2004 to 2011, and actively discouraging screening starting in 2012 (and with its draft in late 2010, as noted by Sitemaster). (In 1996 it issued a recommendation against screening, which it revised upward to inconclusive in 2002, keeping it there until the recommendation against screening in the draft in 2010 and final publication in 2012; I just checked.)

    Per Figure 1 of the full article (available for free), the surge occurred between 2008 and 2010, with no data point plotted for the intervening year, 2009. There was also a smaller but quite obvious increase between 2012 and 2013. Therefore, it seems the smoking gun (or guns) is located somewhere in the time frame of 2008 to 2010. Sitemaster suggests that better imaging accounts for much of the increase (similar to PSA leading to a surge in diagnosis of prostate cancer in the 1990s). Hoping for a technology breakthrough that would help me, I was avidly following developments in imaging during this period, as I was on my third round of intermittent triple ADT, at the 8 year point in 2008, and keenly aware that at some point ADT would no longer control my challenging kind of prostate cancer. (It actually did control it, with no curative therapy attempt, through 13 years, at which point I had apparently successful radiation supported by a final round of ADT3.)

    Imaging was getting much better during this period. On December 13, 2011 I had a NaF18 PET/CT bone scan, regarded as much superior to the traditional technetium based bone scan. At the end of March 2012 I had the feraheme lymph node scan (now considered not sufficiently safe due to rare, potentially fatal allergic reaction), but other scans based on the carbon-11 isotope, still available, were available then, though only in a few locations. Fortunately my scans were, surprisingly, negative, but many of us with challenging cases were getting highly precise targeting information on metastatic locations of our disease. I was not a particularly early adopter, so I suspect that there was a surge in use of such advanced imaging in 2010. At the moment I have not figured out how to check that. (Help?)

    Therefore, while I have yet read only Figure 1 of this paper, it seems that the USPSTF is not the direct cause of the increased detection of metastatic disease. However, in a broader sense, its long-term non-endorsement of screening likely caused, I believe, an unnecessarily substantial proportion of patients to be diagnosed at a point when metastatic disease had developed. That fate was almost surely nearly my own. For years in the 1990s I had heard and accepted that prostate cancer screening was not that effective, and at my first ever screening in 1999 my PSA was 113.6, with a later determined PSA doubling time of 3 to 4 months. A year later my PSA and cancer would have doubled three to four times, with a PSA level exceeding 1,000 within the year and soaring upward. While no metastases were found in 2000 after diagnosis except for one “suspicious” spot in an unlikely location (ProstaScint, now pretty much obsolete), today’s technology might have found metastatic spots.

    I hope men and their loved ones will heed the alarm sounded by this study, and I hope those who have opposed screening will rethink their opposition.

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