Over the past 15 years, public health authorities have downgraded recommendations for the prostate-specific antigen (PSA) test as a screening tool to reduce the overdiagnosis and overtreatment of men with low-grade prostate cancer. Researchers from Weill Cornell Medicine have found that while these efforts have been effective, the incidence of higher-grade disease and metastasis at diagnosis has risen. The research was published by Borregales et al in the Journal of the National Cancer Institute.
To our knowledge, this is the first study to demonstrate nationally that low-grade prostate cancer is no longer the most commonly diagnosed type of prostate cancer.— Jim C. Hu, MD, MPH
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“To our knowledge, this is the first study to demonstrate nationally that low-grade prostate cancer is no longer the most commonly diagnosed type of prostate cancer,” said senior author Jim C. Hu, MD, MPH, the Ronald P. Lynch Professor of Urologic Oncology at Weill Cornell Medicine and Director of the LeFrak Center for Robotic Surgery at NewYork-Presbyterian/Weill Cornell Medical Center. “One of the weaknesses of PSA/prostate cancer screening was that it led to overdetection of indolent cancers that would not harm men, subjecting them to anxiety and future testing.”
In 2012, the U.S. Preventive Services Task Force (USPSTF) recommended against screening all men with the PSA test, concluding that the benefits of the test did not outweigh the risks. Then in 2018, the USPSTF issued a revision to include shared decision-making for the PSA test for men aged 55 to 69 years, reflecting emerging evidence of longer-term benefits and widespread adoption of active surveillance after detection of low-risk disease.
For their study, Dr. Hu and colleagues identified more than 438,000 men with newly diagnosed prostate cancer between 2010 and 2018 using a nationally representative database. They examined trends in the incidence of prostate cancer by disease risk using several measures, including Gleason grade, PSA level, and presence of metastasis at diagnosis. They also investigated whether increasing rates of obesity or the advent of newer diagnostic tools such as prebiopsy magnetic resonance imaging (MRI) and biomarkers might explain incidence trends.
The analysis revealed a significant decrease in the incidence of the lowest-risk prostate cancer, Gleason grade 1, falling from 52 to 26 cases per 100,000 men across all age groups. Further, the proportion of Gleason grade 1 findings on pathology in men who had a radical prostatectomy decreased from 32% to 10%. However, rates of metastases at diagnosis increased from 3.0% to 5.2% over the same period. Halting PSA testing appeared to be the primary driver of these trends.
Implications of the Findings
“The fact that only 10% of radical prostatectomy specimens demonstrate low-grade prostate cancer indicates that even when low-grade cancer is diagnosed, it is being treated much less frequently,” said Dr. Hu. “This demonstrates that there has been acceptance of active surveillance, also known as monitoring with curative intent, among doctors and patients nationally.”
“It is encouraging to see that urologists in the United States have moved away from overutilization of radical therapies for the management of low-risk prostate cancer,” added first author Leonardo Borregales, MD.
“Public health efforts should be directed toward addressing the increase in the diagnoses of metastatic prostate cancer,” the authors concluded. They added that public health authorities should consider implementing risk-stratified screening, for example, with MRI or biomarkers.
Disclosure: For full disclosures of the study authors, visit academic.oup.com/jnci.The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.