As Predicted: Jump in Metastatic Prostate Cancer Diagnoses

M. Alexander Otto, MMS, PA

March 14, 2022

The incidence of metastatic prostate cancer shot up in the United States after the US Preventive Services Task Force recommended against routinely screening men with the prostate-specific antigen (PSA), shows a report published online today in JAMA Network Open.

It was a consequence that many experts in prostate cancer predicted at the time the recommendation was made — initially in 2008 against routine screening in men older than 75 years, and then in all men in 2012.

The thinking was that the harms of screening all men — leading to unnecessary prostatectomies and other treatments in many men — outweighed the benefits of catching early high-risk disease in fewer men. Screening rates plummeted as a result.

But experts in prostate cancer warned that the move, while reducing overdiagnosis and overtreatment, would have the unfortunate consequence of underdiagnosis and, consequently, nondetection of the cases of prostate cancer that would spread. 

The new findings are the latest to suggest that this is, in fact, what happened, and echo similar findings previously reported by Medscape Medical News.  

For this study, investigators at the University of Southern California, Los Angeles, analyzed the incidence of metastatic prostate cancer (mPCa) in the Surveillance, Epidemiology, and End Results (SEER) database from 2004-2018, with 2018 being the latest data available.

SEER captures about 28% of the US population and recorded almost 50,000 new mPCa cases over the period.

Among men 45-75 years old, the incidence of mPCa increased 41% from when USPSTF recommended against screening through 2018, which translated to an annual percentage change (APC) of 5.3%.

Among men 75 years and older, mPCa rates jumped 43% through 2018, an APC of 6.5%.

The researchers did not find an increase in deaths from prostate cancer, but given the 5-7 years median survival, it might be too early to tell.

"The observation of a rising incidence of mPCa in itself does not imply that screening practices should be changed. The overall risk vs benefit of PSA-based screening is extremely complex and must take into account various other factors that impact the overall health of the community," say investigators, led by Mihir Desai, MD, a clinical urology professor at USC. 

However, screening practices have already changed. The USPSTF withdrew its objections to screening in 2018, and instead recommended personalized decision-making for men 55-69 years old, citing new evidence that screening prevents metastatic disease and reduces PCa mortality more than previously recognized, Richard Hoffman, MD, MPH, an internal medicine professor at the University of Iowa, Iowa City, said in an accompanying editorial.

The study’s trends in mPCa "might be transitory because the screening guidelines have" changed, Hoffman writes.

For now, clinicians should "consistently address screening with men who are healthy enough to benefit" from catching dangerous tumors early and engage them "in shared decision-making discussions to" strike the right balance between minimizing overdiagnosis and catching high-risk tumors before they spread, he said.

Easier said than done, but the field is advancing. Active surveillance, instead of surgery, for what seem to be low-risk tumors is one step in the right direction, Hoffman commented. 

No external funding was reported. Desai is a consultant for Procept Biorobotics and Auris Surgical. Hoffman reported royalties from UpToDate and fees from law firms as an expert witness on prostate cancer screening cases.

JAMA Netw Open. Published online March 14, 2022. Full text, Editorial

M. Alexander Otto is a physician assistant with a master’s degree in medical science and a journalism degree from Newhouse. He is an award-winning medical journalist who worked for several major news outlets before joining Medscape and is also an MIT Knight Science Journalism fellow. Email: aotto@mdedge.com

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