More High-Risk Prostate Cancer Now in the US Than Before

                                                                           Pam Harrison, March 27, 2018

COPENHAGEN, Denmark — More men are now presenting with higher-grade, more invasive prostate cancer in the wake of 2012 recommendations from the US Preventive Services Task Force (USPSTF) not to routinely screen asymptomatic patients to detect early disease, more epidemiologic evidence indicates.

As predicted by urologists in 2012 after the recommendations were released, there has been a consistent, stepwise increase in cancers of higher Gleason score, as well as a stepwise increase in the median level of prostatic-specific antigen (PSA), in the 4 years after the USPSTF recommendations were released compared to the 4 years before the recommendations were issued.

At the same time, both surgical volume and the proportion of low-grade cancers have been dropping, as reported by Thomas Ahlering, MD, University of California, Irvine, and colleagues during a poster session of the European Association of Urology (EAU) 2018 Congress.

“Treating high-risk disease has its limitations, because you are not going to cure the majority of patients no matter what you do, so the better answer is to diagnose prostate cancer earlier,” Ahlering told Medscape Medical News.

“If our data are correct, the most important thing to do is to start screening more intensely again,” he reaffirmed.

Two Related Studies

In one of two related studies, Ahlering and colleagues carried out a retrospective analysis of nine high-volume referral centers throughout the United States to compare patients who presented with prostate cancer of Gleason grade 8 or higher and who had seminal vesicle and lymph node involvement before the 2012 USPSTF recommendations were issued with such patients after the recommendations were issued.

A total of 19,602 men were analyzed; 4-year average diagnoses were compared between October 2008 and September 2012, and between October 2012 and September 2016, before and after the recommendations had been released.

The researchers observed a 22.6% reduction in surgical volume in the postrecommendation period compared to the prerecommendation period.

They also noted an increase in the median PSA level from 5.1 ng/mL prior to the recommendations to a median of 5.8 ng/mL after they had been released (P < .001).

The mean age at the time of diagnosis also increased, from 60.8 years before the recommendations to 62 years after the recommendations (P < .001).

“Expectedly, the proportion of low-grade Gleason 3+3 cancers decreased from 30.2% to 17.1% (P < .001),” the investigators write.

In contrast, the incidence of high-grade Gleason 8+ prostate cancers increased from 8.4% prior to the recommendations to 13.5% after the recommendations (P < .001).

“In this Gleason 8+ group, we saw a 24% increase in absolute numbers [of prostate cancer diagnoses]. One-year biochemical recurrence (BCR) rose from 6.2% to 17.5% (P < .0001),” they report.

Ahlering and colleagues also performed a propensity score–matched analysis to rule out the possibility that the increase in high-risk disease was not due to referral patterns.

“For any given age and PSA, propensity matching demonstrates that there is now more aggressive disease in the post-recommendation era,” the researchers report.