One of the best things that ever happened in men’s health was been a steady drop in prostate cancer (PCa) death rates once PSA screening began in the 1990s. Before that, the PCa world was grim because there was no good way to detect early PCa—because it has few-to-no symptoms. Back then, many cases of PCa were found as a result of TURP procedures (transurethral resection of the prostate, or “reaming out”) for enlarged prostates. When the removed tissue was sent to a lab for analysis, their cancer was discovered. “TURP-detected cancers were half of all detected cancers in the mid-1980s, but the proportion of TURP-detected tumors fell off as the use of the procedure declined.”^[i]

Besides TURP procedures, a large percentage of PCa patients were diagnosed based on late onset symptoms such as difficulty urinating, blood in urine, lower back pain or bone pain. This was a sad state of affairs. By the time such symptoms appear, the cancer has usually advanced into the lymph nodes and beyond. At that point, surgical removal or radiation offered slim hope for cancer control, so countless patients were castrated (surgically or with drugs) in order to put the brakes on the cancer. It was not a cure, but it bought time. However, it comes with a price: reduced quality of life.

PSA screening brings a drop in death rates

With the introduction of PSA screening, the PCa-specific death rate started to come down. Although it’s not a perfect biomarker for PCa, a rising or abnormally high PSA was the first widely available, inexpensive way to warn that a man might have the disease. Thus, statistics reveal that a sea change began occurring as we headed into the New Millennium:

• Initially, the incidence of PCa cases rose due to early detection, but the U.S. PCa death rate steeply declined by 30% in the late 1990s.
• By 2008, the mortality rate had declined by 39% since 1991.
• A growing number of men were diagnosed with apparently localized disease; during the period 1999–2006, 80% had localized disease, 12% had regional disease, and only 4% had distant disease.^[ii]
• A Danish study compared two population groups, screened vs. nonscreened men. Compared with a higher rate of metastatic disease and PCa-specific death in the nonscreened men, the screened men had 53% less PCa metastasis at diagnosis, and 37% fewer PCa-specific deaths after 8.5 years of follow-up.^[iii]
• A 2000 study reporting on two mathematical models stated that, according to calculations, 45% to 70% of the observed decline in prostate cancer mortality could be plausibly attributed to the stage shift induced by screening.^[iv]

Progress in death rates stops

The above statistics are not merely academic. They are important evidence that much of the drop in PCa mortality can be credited to PSA screening, as well as treatment advances. Now, a 2022 study highlights a concerning phenomenon: stagnation in the drop. In other words, the death rate is either staying the same, or even slightly rising.

The May, 2022 paper published by Burgess, et al.^[v] finds that the 2012 U.S. Preventive Services Task Force (USPSTF) recommendations against broad PSA screening may be associated with a gradual stop to falling PCa-specific mortality. By tracking deaths between 2013-2019, they concluded that rates had “…flattened or increased after the 2012 USPSTF Grade D recommendation, suggesting that decreased PSA screening may be a factor associated with this change. This change was seen across ages, races and ethnicities, urbanization categories, and US Census regions.”

This is very sad, given that other factors were also contributing to lower death rates since 2000. These factors include better imaging detection using multiparametric MRI (mpMRI) with PI-RADS scoring; in bore MRI guided targeted biopsies for superior accurate diagnoses; and innovative treatment methods in surgery, radiation and ablation (including focal therapies). If the Burgess team is correct, their analysis implies that the rather abrupt drop in wide screening after 2012 has had the effect of canceling out much of the clinical progress we’ve accomplished in two decades.

That said, the researchers offer a ray of hope: the 2018 USPSTF recommendation that supports shared decision-making between patient and physician may help PSA screening resurge. If so, I believe that mpMRI plays a huge part in supporting such a renaissance. Doctors and patients need no longer fear that PSA screening might lead to overdiagnosis and overtreatment. Thanks to adding mpMRI as an immediate next step following an abnormal PSA, we can avoid unnecessary biopsies, and we can match treatment planning—including Active Surveillance—so that men can avoid overtreatment and its related side effects.

The Sperling Prostate Center has consistently emphasized the importance of annual PSA screening according to professional guidelines, and its integration with mpMRI to further refine it. In this way, we hope that we can resume an ongoing decline in PCa-related mortality so patients can achieve a full and satisfying lifetime.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Brawley OW. Trends in prostate cancer in the United States. J Natl Cancer Inst Monogr. 2012;2012(45):152-156.
[ii] Ibid.
[iii] Van Leeuwen PJ, Connolly D, Gavin A, Black A et al. Prostate cancer mortality in screen and clinically detected prostate cancer: estimating the screening benefit. Eur J Cancer. 2010 Jan; 46(2):377-383.
[iv] Etzioni R, Tsodikov A, Mariotto A, et al. Quantifying the role of PSA screening in the US prostate cancer mortality decline. Cancer Causes Control. 2008;19(2):175-181. doi:10.1007/s10552-007-9083-8
[v] Burgess L, Aldrighetti CM, Ghosh A et al. Association of the USPSTF Grade D Recommendation Against Prostate Specific Antigen Screening With Prostate Cancer–Specific Mortality. JAMA Netw Open. 2022; 5(5): e2211869.