Prostate Cancer Deaths to Decrease, Yale Researchers Predict

The current projection for prostate cancer deaths is that they will increase, based on the Global Health Observatory. But the statistics that they provided failed to account for the granularity of the increases in technology specifically geared toward prostate cancer screening and detection. When we look at trends from the 1990s to now, there has actually been a steady decrease in prostate cancer mortality despite an increase in the incidence of prostate cancer.

The National Cancer Network and the American Urologic Association (AUA) guidelines encourage shared decision making between the patient and clinician. For those at higher risk—African American men, those over the age of 45, or those with a family history of prostate or urologic cancers—the discussion should be introduced to the patient in a primary care setting, as well as in the urology office if a patient is presenting for other issues.

Traditionally, screening has been through a digital rectal exam, which has very poor sensitivity for detecting lower stage prostate cancer. Then, the 1990s saw broad enthusiasm for using the prostate specific antigen (PSA) blood test which dramatically increased detections but also sparked concerns regarding over-diagnosis and over-treatment. With that, the U.S. Preventative Services Task Force guidelines evolved in 2012 to a probably overly cautious recommendation against PSA screening.

This generalization has since been refined by the AUA within the last decade to emphasize shared decision making and taking into consideration a patient’s risk factors, integration of high-quality prostate MRI [magnetic resonance imaging], biomarkers, and refined biopsy protocols to minimize harms while targeting clinically significant prostate cancer.

First, there’s more comfortability around the discussion of prostate cancer than there has been in the past. Social media has played a positive role in promoting the greater comfort that men have in talking about this with their physician, as well as with their family members.

Then, there have been novel developments in rapid test kits for the screening of PSA. Different risk stratifiers have also been developed to help assess patients based on their family history and biopsy results. The incorporation of MRI as a standard test for patients with elevated PSA can help us detect suspicious lesions, and the development of the Prostate Imaging Reporting and Data System score to be used in combination with MRI imaging helps us better identify those with prostate cancer.

We argue strongly that the main way mortality will decrease is through increased accessibility and screening, so these advances are promising.

One of the challenges associated with increased screening is that, although PSA testing has a relatively high sensitivity for detecting prostate cancer, it carries a risk of false positives, potentially leading to unnecessary biopsies. However, despite these false positives, improved screening will result in more true positives cases. Thus, more individuals with clinically significant prostate cancer will receive appropriate treatment.

We anticipate the overall incidence of prostate cancer to increase based on the aging population, which is the main argument for why some experts believe there will be a mortality increase. More exciting is the emergence of focal treatments that focus on the improvement of the quality of life of patients with clinically significant prostate cancer that require surgical intervention. By focusing on specific diseased tissues, focal therapy reduces the collateral damage on sexual and urinary function.

We are also introducing new surgical interventions here at Yale for patients with metastatic prostate cancer that otherwise have limited treatment options. One trial in process is the Surgery in Metastatic Carcinoma of Prostate (SIMCAP) trial, which involves patients with metastatic prostate cancer undergoing surgical removal of the prostate. Other trials also exist involving the testing of new immunobiologics in combination with androgen deprivation therapy. We foresee that the introduction of new trials will also help decrease the overall morbidity and mortality of prostate cancer.

Countries with less access to new developments in care will suffer the most in terms of the mortality rate. Men of African origin have been known to be at high risk for aggressive prostate cancer and unfortunately, due to years of health care inequities, tend to be the most medically underserved. But we foresee, because of the rapid development of technology and accessibility to global care within more developed countries, that this technology will spread, thus helping the global population.

It comes down to awareness. One of the main issues is access to care and socioeconomic status. Social media and discussion of the topic amongst primary care providers can lead to us detecting prostate cancer at earlier stages so we can prevent those adverse outcomes that we see in patients that present at later stages of prostate cancer. Early treatment and detection will decrease mortality and adverse prostate cancer outcomes. The beauty of social media is how it improves the accessibility of information worldwide. We anticipate increased awareness for prostate cancer screening globally.

We at Yale are very optimistic. Even within our own department, we have seen advancements in treating patients with metastatic disease, the increase in screening, improvement in morbidity associated with therapies, and the decrease in mortality over the last two decades. It is very remarkable how few incisions we make these days to surgically treat prostate cancer. We are optimistic that trends will continue to, if not decrease, at least stay the same as the incidence of prostate increases in our aging population.