A rise in late-stage prostate cancer diagnoses has doctors on alert

U.S. Cancer Death Rate Has Dropped by a Third Since 1991: A rise in late-stage prostate cancer diagnoses has doctors on alert. repost: The Wall Street Journal By Brianna Abbott

The cancer mortality rate in the U.S. has dropped by a third in the past three decades, a report showed, but an increase in advanced prostate cancer diagnoses threatens to reverse some hard-won gains.  

The American Cancer Society said Thursday that changes in preventive measures and screening in the past decade drove important trends in U.S. cancer incidence and outcomes. Cervical cancer rates dropped 65% from 2012 to 2019 among women in their early 20s after a generation of young women were vaccinated against human papillomavirus, or HPV, for the first time.

But a decline in the use of a controversial test for prostate cancer likely led to more men getting diagnosed at later stages, the report found, with the highest incidence and mortality among Black men. The ACS said it would invest in research on prostate cancer and programs to boost access to quality screening and treatment.

“There’s a significant call to arms,” said Karen Knudsen, ACS’s chief executive officer. “We are not catching these cancers early when we have an opportunity to cure men of prostate cancer.” 

The report was published in the journal CA: A Cancer Journal for Clinicians. The authors at ACS analyzed federal and state cancer registries for data on cancer rates through 2019 and federal mortality data through 2020, the report said.

Cancer is the second-leading cause of death in the U.S., behind heart disease, with nearly 2 million cases and some 610,000 deaths estimated to occur in 2023, the ACS said. The decline in smoking rates in the U.S., better early detection and innovative treatments including immunotherapy drugs have driven a drop in death rates since 1991, the report said, averting an estimated 3.8 million cancer deaths in that time.

The vaccine for HPV, a sexually transmitted virus that can cause cervical and other types of cancer, is one success story, ACS said. The Food and Drug Administration approved the first HPV vaccine in 2006 for girls and women ages 9 to 26. The youngest in that group are now adults, and cervical cancer rates for women in their early 20s have dropped more than expected from screening alone.

Rates even among unvaccinated women in that age group declined to a lesser degree, suggesting a herd immunity-like effect from the vaccine reducing the virus’s spread, the report said. 

“It’s really, really remarkable,” said Elizabeth Platz, a professor of epidemiology and co-leader of the Cancer Prevention and Control Program at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins. “It’s a cancer that we could almost eliminate through the combination of screening and vaccination.” 

Dr. Platz said a remaining challenge is increasing HPV vaccine uptake. In 2021, 79% of U.S. adolescent girls had received at least one dose, and 64% were up-to-date, ACS said. The vaccine was also approved for boys and young men in 2009, and doctors said they were optimistic that the vaccine could similarly affect other HPV-related cancers.

For prostate cancer, the second leading cause of cancer death among men after lung cancer, rates of advanced diagnoses have risen about 4.5% annually since 2011, the report found. The proportion of men diagnosed with later-stage disease has doubled. Declines in mortality rates have leveled off. 

The shift is due at least in part to changing guidelines and controversy surrounding the prostate cancer screening tool, called a PSA test, cancer epidemiologists said. The PSA test looks in the blood for levels of a prostate-specific antigen, or PSA, which can be higher among men with prostate cancer and other conditions. The test was deployed widely when it was introduced, causing a surge in detected prostate cancer cases in the early 1990s. 

Many cases, however, were slow-growing or asymptomatic. Evidence on the screen’s overall benefit in preventing deaths was mixed, and doctors said some patients would undergo unnecessary biopsies or treatments that could cause harm.

A government-backed task force recommended against the test for older men in 2008 and all men in 2012, after which detected incidence rates fell again. Following additional research, the group said in 2018 that men ages 55 to 69 should decide with their doctor whether to undergo the test, concluding that its risks and benefits were closely balanced for men in that age group.

“We’re seeing some of the consequences of diminished screening,” said Dr. Jonathan Shoag, associate professor of urology at University Hospitals Cleveland Medical Center and Case Western Reserve University, who has studied PSA testing for prostate cancer. “We’re not detecting cancers we don’t want to know about, but the cancers that we’re finding are worse cancers.” 

Black men might benefit more from PSA screening, the ACS report said. Prostate cancer mortality rates are two to four times higher for Black men compared with those in other groups. 

The ACS said that it is revising its screening guidance and that researchers are exploring what might increase risk for aggressive disease to better target screening and treatment. Doctors could use PSA test results, combined with tools such as better MRI imaging and genetic information, to make more informed decisions about their patients’ cancer risk and how best to proceed, ACS executives said. 

“We can no longer stand back and not act,” ACS’s Dr. Knudsen said.