Overall cancer mortality rates have decreased 33% since 1991, and cervical cancer incidence decreased 65% from 2012 through 2019, according to the latest statistics reported by the American Cancer Society (ACS).1 Amid this good news, however, was a troubling 3% annual increase in prostate cancer incidence from 2014 through 2019, after 2 decades of decline, “translating into an additional 99,000 new cases.”1
On the PBS NewsHour, Karen E. Knudsen, MBA, PhD, Chief Executive Officer of ACS and the ACS Cancer Action Network, stated that the increase in prostate cancer, particularly the 4.5% increase in prostate cancer diagnosed at an advanced stage, was a “call to arms.”2 In a subsequent interview with The ASCO Post, Dr. Knudsen said that physicians and patients should “respond to the call to arms through engagement with prostate cancer screening.”
Karen E. Knudsen, MBA, PhD
Data on prostate cancer screening rates, dating back to 2018, “suggested that only one-third of men across the country, both Black men and White men, were engaged in prostate cancer screening,” Dr. Knudsen said. “We are very concerned about that, because this is a cancer type where survival rates are 99% if caught early, but we have no durable cure for metastatic disease. Prostate cancer remains the second leading cause of cancer deaths in men (cancers of the lungs and bronchi constitute the number one cause), which is a problem. It is telling us that these cancers are being caught too late, and the data we reported this year, seeing the shift in diagnosis to more advanced disease, are proof positive that we can and need to do more for men. Screening is key.”
Changing Guidelines
“After about 20 years of declining incidence, the first increase in prostate cancer—especially in late-stage diagnoses—likely results from changes to PSA [prostate-specific antigen] screening guidelines,” according to an ACS article accompanying the release of the new statistics.3 Amid concerns about overdiagnosis and overtreatment of prostate cancer, the U.S. Preventive Services Task Force (USPSTF) changed its screening guidelines to recommend against routine prostate cancer screening with PSA testing. Men older than 70 should not have PSA testing, the task force advised, and men between the ages of 55 and 69 should make individual decisions after discussions with clinicians.
“Fewer men getting screened led to rapid declines in the diagnosis of prostate cancer,” the ACS statement noted, and fewer cancers diagnosed at an early stage. “As a result, the proportion of prostate cancers diagnosed at a distant stage has more than doubled over the past 10 years.”
Current ACS recommendations call for physicians to talk to their male patients with an average risk of developing prostate cancer at age 50, and patients between 40 and 45 at higher risk, and help them make an informed decision about PSA testing. Those recommendations are now being reevaluated.
“It is a research study,” Dr. Knudsen explained. “Experts from across the country are sifting through all of the evidence.” ACS staff “do not tip our hand in that process,” she noted. “We gather the group, which should be opining later this year, and then we will be reviewing the evidence and publishing the guidelines.”
These guidelines will be for men at average risk of prostate cancer. “However, we know there are individuals who need to take particular care—someone with a family history, a brother, a father who had prostate cancer, but also a family history of breast or ovarian cancer, especially if those cases are known to be BRCA-related—who need to be screened early,” Dr. Knudsen noted. “In addition, African American men should likely be screened earlier.” In the future, she added, “we need to make sure the guidelines are adaptable and amenable to a sliding scale of risk based on what we know from the state of the science.”
The data [in prostate cancer trends] we reported this year, seeing the shift in diagnosis to more advanced disease, are proof positive that we can and need to do more for men. Screening is key.— Karen E. Knudsen, MBA, PhD
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Addressing Disparities
African American men have higher incidence and mortality rates for prostate cancer, and “the new screening guidelines will certainly take that information into account,” Dr. Knudsen said. “We don’t have a complete picture about why that disparity persists. The screening data don’t necessarily point to differences in screening having a role, but when the screening rates are so low, there is certainly going to be a benefit from more uptake of screening,” she said.
“However, there has to be more to the story. So, the American Cancer Society is committing to funding research that’s intended to understand these disparities and working with our advocacy and patient support groups to overcome known barriers,” Dr. Knudsen stated.
“We strongly suspect that some of the disparities may result from access to quality cancer care at the time of diagnosis. That is something we need to assess and understand more fully across the nation,” she continued. “How much of this is attributable to differences in risk? We know very little about the genetics of risk for men of African descent, compared to the wealth of knowledge we have for Caucasian men of European descent. So, certainly, research needs to be conducted there.”
HPV Vaccination Success
The 65% drop in cervical cancer incidence “foreshadows steep reductions in the burden of human papillomavirus [HPV]-associated cancers,” according to the new statistical report. The concept that the impact of the HPV vaccine extends beyond cervical cancer is still not well understood, Dr. Knudsen said. “In future years, we will be looking for the changes in other HPV-related cancers, like head and neck cancers and anal cancers.” Reductions in HPV-associated cancers might be seen later for men than women because HPV vaccination was initially recommended specifically for females.
“The first indication was just for girls, and it is almost as though we are frozen in time for that initial rollout,” Dr. Knudsen said. “The fact that both boys and girls need to be vaccinated is still an area of opportunity for us as a country.”
She continued: “Unfortunately, the HPV vaccine was initially rolled out as a sexually transmitted disease vaccine, and trying to educate the public about what this vaccine is and what it is not has required some reeducation. The fact that it is a cancer vaccine has not permeated the U.S. population consciousness sufficiently. Through our advocacy groups and our patient support groups in 5,000 communities across the country, we are working very hard to educate about the importance of HPV vaccination.”
Not Just for Children
Among the issues Dr. Knudsen finds “most disconcerting when traveling about the country is the lack of awareness about who is eligible to be vaccinated. There is the thought that this is just for children and that if you missed it—if you are an adult—you are no longer eligible. But there are clear criteria for those 26 and younger to be vaccinated and for those 45 and younger to have a conversation with their physician about vaccination. We have a long way to go to ensure that everyone who can benefit from the vaccine will benefit from the vaccine.”
The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) recommends HPV vaccination at age 11 or 12, although it can be started as early as age 9. “HPV vaccination is recommended for all persons through age 26 years who were not adequately vaccinated earlier,” as noted in a National Cancer Institute statement on HPV vaccines.4 “Although the HPV vaccine is U.S. Food and Drug Administration–approved to be given through age 45 years, HPV vaccination is not recommended for all adults aged 27 through 45 years. Instead, ACIP recommends that clinicians consider discussing with their patients in this age group who were not adequately vaccinated earlier whether HPV vaccination is right for them. HPV vaccination in this age range provides less benefit because more people [in this group] have already been exposed to the virus.”
[W]hen the screening rates are so low, there is certainly going to be a benefit from more uptake of screening…. However, there has to be more to the story.— Karen E. Knudsen, MBA, PhD
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Research-Based Advances
The ACS annual statistics report recognizes that “progress increasingly reflects advances in treatment,” particularly for leukemia, melanoma, kidney cancer , and lung cancer. Dr. Knudsen expects that in the future, we will see additional indications for refining immunotherapy combinations or using them at different stages of disease.
She also predicted that “new imaging strategies are going to dramatically change our ability to detect cancer earlier and develop new strategies for true eradication earlier in the disease course. We are very much interested in advancing that science through our granting mechanisms.”
Impact of COVID-19
“Compared with what the scientific community was accustomed to, the vaccine for COVID was developed at an entirely new speed due to the sense of urgency—and with a new strategy, showing that an mRNA vaccine could be effective,” Dr. Knudsen said. “That experience combined with the success of the HPV vaccination has the oncology community thinking more deeply than ever about the role of vaccination in the prevention and treatment of a number of different intractable cancer types.”
The recently released ACS cancer statistics include data through 2019. “So, we have yet to report out data from during the COVID pandemic,” Dr. Knudsen noted. “If we had to predict, given the 22 million screenings that were missed during the pandemic, we are expecting to see first a decline in cancer incidence, and then, unfortunately, we may see an increase in cancer mortality because of those declines in screening and postponed treatment.”
DISCLOSURE: Dr. Knudsen reported no conflicts of interest. She is employed by the American Cancer Society, which receives grants from private and corporate foundations.
REFERENCES
1. Siegel RL, Miller KD, Wagle NK, et al: Cancer statistics, 2023. CA: Cancer J Clin 73:17-48, 2023.
2. Nawaz A: Cancer deaths drop, but more late-stage prostate cancer diagnoses spark concerns. PBS NewsHour, January 13, 2023. Available at www.pbs.org/newshour/show/cancer-deaths-drop-but-more-late-stage-prostate-cancer-diagnoses-spark-concerns. Accessed February 15, 2023.
3. McDowell S: Incidence drops for cervical cancer but rises for prostate cancer. American Cancer Society, January 12, 2023. Available at www.cancer.org/latest-news/facts-and-figures-2023.html. Accessed February 15, 2023.
4. National Cancer Institute: Human papillomavirus (HPV) vaccines. Reviewed May 25, 2021. Available at https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-vaccine-fact-sheet. Accessed February 15, 2023.
