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Studies Question Wisdom of Stopping Previously Successful Efforts at Early Detection and Treatment of Prostate Cancer

Besides nonmelanomatous skin cancer, prostate cancer is the most common cancer in men, as well as the second most common cause of cancer death in American men.  (See figure 1 below.)

Top Ten Male Cancers

Figure 1: Prostate Cancer Incidence (United States)

Source: U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2013 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2016. Available at: www.cdc.gov/uscs.

 

In our state of Louisiana, prostate cancer is even more prevalent. Compared to national averages, more men are diagnosed with prostate cancer in Louisiana (as a function of population) and more men die of prostate cancer in Louisiana. (See figure 2 below.)

Top Ten Cancers Louisiana vs US

Figure 2: Prostate Cancer Incidence (Louisiana)

Source: U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2013 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2016. Available at: www.cdc.gov/uscs.

 

Despite these sobering statistics, we've made progress with this all too common disease.  Take a look at the figure 3 below.  Notice how prostate cancer mortality (death rate) had been slowly increasing, until about 1993.  Then by 1995 the mortality rate began a slow but steady decline.  This declining prostate cancer death rate continued until the last year that we have complete statistics in 2013.  

 

Prostate Cancer Mortality Over the Years -- SEER Data

Figure 3: Prostate Cancer Age-adjusted Mortality Over Time

Source: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, Surveillance Epidemiology and End Results (SEER) Program, 2015. Available at: https://seer.cancer.gov/faststats/selections.php?#Output

This successful assault on prostate cancer led to questions as to how this was accomplished. Why have we seen such remarkable success with lives saved from this sometimes deadly disease? Wouldn't you think that these successful measures might be lauded by the healthcare community and used as a world-wide model for cancer care? Unbelievably, this was not the case (see "USPSTF" below).

Before addressing questions as to the failure for our healthcare system to follow the proven successful model of prostate cancer diagnosis and treatment, let's first look at the factors which made the model so successful.  As can be seen in figure 4 (below) as well as in an animated prostate cancer graphic, the incidence (rate of diagnosis) of prostate cancer increased in the late 1980's. Move the cursor at the bottom of the graph to slowly move the cursor at the bottom of the page form the year 1975 through 2013. 

In the late 1980's, the increased rate of diagnosis of prostate cancer likely was at least partially due to the implementation of prostate ultrasound.  Ultrasound allowed urologists to visualize the prostate in order to perform prostate biopsies.  It was a real advancement over the "blind" biopsy techniques used previously. 

Prostate Cancer Incidence Over the Years -- SEER Data

Figure 4: Prostate Cancer Age-adjusted Incidence Over Time

Source: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute, Surveillance Epidemiology and End Results (SEER) Program, 2015.  Available at: https://seer.cancer.gov/faststats/selections.php?#Output

 

Now, take a look again at Figure 4 (above), as well as the animated graph.  Move the cursor at the bottom of the graph to the early 1990's (for example 1992 and 1993).  There was a prominent spike in the number of prostate cancer diagnoses, in the early 1990's.  As you see, the incidence of prostate cancer skyrocketed at that time.  Clearly, the reason for this phenomenon was PSA (prostate specific antigen).  This simple blood test became (and remains to date) the only widely recognized cancer screening blood test in all of medical history.  This changed everything!

As seen in the animated graph, in the 1990's the numbers of cases of prostate cancer increased across ALL age groups.  Huge numbers of men were diagnosed and treated based on PSA, ultrasound and also a growing new awareness of the importance of early diagnosis and treatment of this the most common male cancer.

Notably, it was in the early 1990's that our Northlake Urology physicians were doing their surgical training; performing prostate cancer surgery practically every day, often performing prostate cancer surgery several times per day.  The training was intense, to say the least.  At no time before or since, have so many prostate cancer surgical cases been performed.

Well, what do you think happened after all of those men who were diagnosed and treated in the 1990's? Take another look at figure 4 and the animated graph.  By the early 2000's the prostate cancers diagnoses were down again, even lower than before PSA and ultrasound were developed.  As importantly, older men were by then being diagnosed less frequently and younger men more frequently.  This shift in the age and stage of diagnosis is to this day recognized as a founding tenant of any successful cancer program.  For most cancers, the only real chance of "cure" is to make the diagnosis and perform treatment at an earlier stage, when cure is possible. 

With wide spread PSA testing and advancing cancer treatments of men at earlier stages of cancer, some real headway was made.  With these explanations provided, it's now time to consider something much more important than diagnosis.  Let's now look at survival.  Did all of the early diagnosis and treatment really help?

Figure 4 (below) and another animated prostate cancer graphic tell the story.

A recent article published in Urology Times suggests disturbing trends in the management of prostate cancer. Researchers at the University of Michigan examined a cancer database revealing a 42% decrease in the diagnosis of prostate cancer between the years 2007 and 2012. At a quick glance this might appear to be good news. However, this is not to imply that there is less prostate cancer. Rather, the issue may be that physicians and patients have become less aggressive when it comes to having men be checked for the disease. Why might this be? Governmental funded organization known as the United States Preventive Services to Task Force (USPSTF) recommended against prostate cancer screening in older man in 2008, before recommending against prostate cancer screening altogether in 2012.

 

 

 

Catalona WJ, D'Amico AV, Fitzgibbons WF, Kosoko-Lasaki O, Leslie SW, Lynch HT, et al. What the U.S. Preventive Services Task Force Missed in Its Prostate Cancer Screening Recommendation. Ann Intern Med. 2012;157:137-138. doi: 10.7326/0003-4819-157-2-201207170-00463