Spotlight on Health
PROSTATE CANCER 2015
Progress made but the cause for optimism may be short-lived
by Thomas E. Moody, M.D.
Prostate cancer is the most common cancer in American men after skin cancer. One in six men in the U.S. will get prostate cancer sometime during their lifetimes. It is the second-leading cause of cancer deaths among American men after lung cancer. Since the widespread use of PSA-based prostate cancer screening in the mid-1980s, the death rate from prostate cancer has been reduced by 40%. This encouraging trend has continued nationwide.
Of special note in Alabama, the disparity in outcomes between the white and black races has narrowed. Fifteen years ago, the stage at diagnosis of prostate cancer was significantly different between the races. Most white men were early stage at diagnosis so more easily treated and probably curable, whereas most black men were late stage at diagnosis and therefore probably not curable.
Over the past three years, statistics from the Alabama Department of Public Health (ADPH) reveal an amazing shift or elimination of this disparity. The percent of men diagnosed with early stage prostate cancer is identical for whites and blacks. Also, the mortality among blacks from prostate cancer has declined significantly. This trend in Alabama coincides with a sustained effort by ADPH and its non-profit partners to conduct regular screenings among high-risk populations, especially in the Black Belt region of the state. And I believe that this sustained effort has paid off.
In 2012, however, the United States Preventive Services Task Force recommended that prostate cancer screening be stopped for all men, all races, and all ages. The result has been a widespread reduction in prostate cancer screening. For example, as shown by the extensive Medicare claims database of RealTime Medicare Data (RTMD), over the 2011-2014 period, there has been an aggregate decline of almost 11% in PSA screenings among Medicare beneficiaries in the 18 states studied (see Figure 1), and there has been as much as a 25% decline in some states (see Table 1).
As screenings decline, the “incidence” of prostate cancer may also appear to have declined, but prostate cancer has not gone away–it is just not being diagnosed at the same rate.
If this trend continues, I anticipate there will be a large group of men who will not have the benefit of early diagnosis, and that by the time this group of men discovers their disease, it will not be in an early stage and so probably will not be curable.
Surprisingly, the Task Force had no urologist, medical oncologist, radiation oncologist, or any physician that treats cancer of any kind among its members. The Task Force cited over-diagnosis, over-treatment, complications of diagnostic procedures (i.e., prostate biopsies), complications of active treatment such as impotence and incontinence as well as the costs involved, as reasons to cease prostate cancer screening.
I believe this is a very short-sighted approach. The concerns raised are legitimate, but instead of going back to a time when most prostate cancers were in advanced stages at diagnosis, it seems more prudent to address the concerns. Thankfully, that is being done. Major advances are being made in the diagnosis of prostate cancer through novel blood tests and more accurate biopsy methods. Also, genetic and molecular testing are helping to determine which cancers are dangerous and need treatment and which ones can be safely watched. Treatment modalities have improved so that the adverse effects have been reduced.
The future of prostate cancer management should not be to ignore it but to address it so that the significant advances in prostate cancer mortality can be preserved and improved while also improving the quality of life for men with prostate cancer.
Any views expressed above are the author’s own and do not necessarily reflect the views of RTMD.