Prostate Cancer Incidence and Survival, by Stage and Race/Ethnicity

United States, 2001-2017

David A. Siegel, MD; Mary Elizabeth O'Neil, MPH; Thomas B. Richards, MD; Nicole F. Dowling, PhD; Hannah K. Weir, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(41):1473-1480. 

In This Article

Discussion

Although approximately three fourths of U.S. men with prostate cancer have localized stage at diagnosis, an increasing number and percentage of men have received diagnoses of distant stage prostate cancer. Survival with distant stage prostate cancer has improved, but fewer than one third of men survive 5 years after diagnosis. Survival disparities by age and race/ethnicity were noted for distant stage prostate cancer during all three periods (i.e., 2001–2005, 2006–2010, and 2011–2016) studied.

The U.S. Preventive Services Task Force (USPSTF) has issued several recommendations that discuss the possible benefits and harms of screening for prostate cancer using prostate-specific antigen (PSA).††† In 2012, USPSTF concluded that the benefits of PSA-based screening do not outweigh the harms and recommended against PSA-based screening for prostate cancer for men of all ages. This recommendation likely contributed to a decrease in overall reported prostate cancer incidence and might have contributed to an increase in the percentage and incidence of distant stage prostate cancer.[2,3] Despite decreasing incidence of localized stage prostate cancer, 130,658 to 190,570 new cases were diagnosed each year in the United States during 2003–2017. Even though 10-year survival for localized stage prostate cancer is 100%, many of these patients need treatment, including surgery or radiation, often face long-term effects of their treatment (e.g., urinary incontinence and erectile dysfunction), and ≤6% progress to metastatic prostate cancer.[6] Improvements in survival for distant stage prostate cancer might reflect changes in clinical management, which includes increased use of new agents and treatment innovations, such as new hormone and antibody therapies.[6] Despite these improvements in survival, increases in distant stage prostate cancer incidence might have contributed to the plateauing of previously declining prostate cancer mortality during 2013–2017.[1,2]

Five-year survival for all stages combined was higher for White men than Black or Hispanic men. However, survival for distant stage prostate cancer was higher for Black than White men, which is different from a past study reporting higher survival for White men than Black men during 2001–2009, but with overlapping 95% CIs.[4] In addition, unknown stage prostate cancer represented a higher percentage of total cases (7%) than distant stage prostate cancer (5%), and survival for unknown stage prostate cancer was higher for Hispanic and White men than Black men. Men in the unknown stage category, who had a 5-year relative survival of 84.3%, might include a mixture of situations, such as men not healthy enough for a staging workup, situations where staging is not needed to guide treatment decisions, lack of access to care, or incomplete recording in the medical record.[7] Past data suggest that social inequities by race contribute to worse outcomes for Black men than White men with prostate cancer.[8] Survival based on distant stage and race/ethnicity might need to be interpreted in the context of the incidence and survival for other prostate cancer stages, as well as diagnostic procedures and social determinants of health such as access to care.[7,8]

Although survival by age varied by stage, survival was lowest for ages >75 years for regional, distant, and unknown stage prostate cancer. Lower survival for distant stage at age >75 years compared with younger ages might be secondary to more rapid development of resistant prostate cancer, reduced ability to receive available therapies, and impact of comorbidities.[5] Ten-year survival was lower for men aged ≤49 years compared with all ages except ≥80 years. Prostate cancer incidence in men ≤49 years has risen over the past 3 decades, and lower survival for this age group has been reported.[9] Prostate cancer behavior, genetics, family history, and treatment patterns might affect prostate cancer incidence and survival patterns for men aged ≤49 years.[9]

The findings in this report are subject to least three limitations. First, prostate cancer cases missing from the dataset could result in an undercount of prostate cancer incidence,§§§ and delays in reporting could undercount incidence over the most recent years of the study.[10] Second, Collaborative Cancer Staging coding, which was used from 2003 to 2015 to code stage data, might explain the lower numbers of unknown stage cases during those years.¶¶¶ Finally, confidence intervals could not be generated for all survival results that are rounded to 100.0%, and values listed as 100.0% only mean that no excess deaths were observed.

In 2018, USPSTF issued a new recommendation stating that prostate cancer screening for men aged 55–69 years should be an individualized decision based on personal preferences when weighing the benefits and harms of screening,**** and several professional organizations have similarly recommended shared decision-making for men deciding about prostate cancer screening.†††† Understanding incidence and long-term survival by stage, race/ethnicity, and age could inform messaging related to the possible benefits and harms of prostate cancer screening and could guide public health planning related to treatment and survivor care. Further research is needed to examine how social determinants of health affect prostate cancer diagnosis and treatment; findings should inform interventions to decrease disparities in outcomes.

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