New evidence is raising concerns that federal recommendations against routine prostate cancer screenings may be contributing to a drop in early detection of the disease and a continued rise in advanced cases.
Diagnoses of localized prostate cancer in men over age 50 decreased by nearly 7% per year from 2007 to 2016, according to the analysis. In those cases, there is no sign of cancer spreading outside the prostate gland.
By contrast, regional cases, where the cancer has spread just outside of the prostate, remained stable from 2005 to 2012 but increased by more than 11% per year from 2012 through 2016.
Similarly, incidences of distant-stage prostate cancer where the illness had already spread beyond the pelvis and into other parts of the body rose by 5% per year from 2010 to 2016 after annual declines of nearly 1% from 2005 to 2010. The findings were published Wednesday in the Journal of the National Cancer Institute.
The rise in late-stage prostate cancer cases accompanied by drops in detection of early-stage disease coincides with a decrease in screenings over the study period. Researchers found prostate cancer testing among men age 50 and older declined from more than 40% in 2008 to 32% by 2015.
Study lead author Dr. Ahmedin Jemal, scientific vice president of surveillance and health services research for the American Cancer Society, said the findings suggest the severity trend could be a byproduct of the U.S. Preventive Services Task Force's recommendations against routine prostate-specific antigen-based screening for men 75 and older in 2008. That recommendation was expanded for all men in 2012.
At the time the panel determined there wasn't enough evidence showing routine prostate cancer screening had benefits that outweighed potential harms for those at average risk. Increased testing can mean higher risks of false-positive results, overdiagnosis and overtreatment, and complications from treatment.
The task force changed its guidelines in 2018 to recommend that 55- to 69-year-old men talk with their clinicians about the benefits and harms associated with prostate screening, letting each patient decide about testing.
Prostate is the second-most common type of cancer in U.S. men. Approximately 191,000 new cases of prostate cancer are estimated to occur in 2020, according to the American Cancer Society, resulting in more than 33,000 deaths.
While five-year survival rates for both localized and regionalized stages of the disease are nearly 100%, only 31% of patients live past five years once the cancer gets to the distant stage.
Jemal said the study's findings warrant taking another look at the task force recommendations to see whether a better balance can be struck in prostate screening that increases earlier detection of the disease while mitigating potential harms from testing.
"There should be a discussion, but that discussion is not taking place," Jemal said.
Dr. Edmund Folefac, genitourinary medical oncologist with Ohio State University's Comprehensive Cancer Center, said the study's findings were not surprising given the increased number of first-time patients he has seen coming into his clinic who already have advanced stages of prostate cancer.
Folefac said the task force's 2018 recommendation change was too small a step to affect screening rates because it requires patients to decide rather than those trained in making more-informed testing assessments. "I just find it incredible that someone would put the onus on them," Folefac said. "The patients didn't go to medical school."
The task forces' current guidelines provide information to help higher-risk groups like African American men and men with a family history of prostate cancer make more-informed decisions about screening.
But the task force's "C" rating for prostate screening does create a potential barrier even if men decide to get tested. Under the Affordable Care Act health insurers are required to provide coverage of preventive services like screenings without cost sharing if the task force gives the recommendation a rating of "A" or "B." Any rating below a "B" makes it less likely payers will cover the total costs, possibly deterring some men from getting a test because of cost concerns.
"We need a paradigm in the way that we organize healthcare and put more emphasis on prevention," Folefac said. "That's the best way to give our patient populations the healthcare that they need."