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Figure 1.
Delay-Adjusted Incidence (per 100 000 Men) and Incidence Ratio for Localized/Regional Prostate Cancer by Age Group, Surveillance, Epidemiology, and End Results 18, 2005-2013
Delay-Adjusted Incidence (per 100 000 Men) and Incidence Ratio for Localized/Regional Prostate Cancer by Age Group, Surveillance, Epidemiology, and End Results 18, 2005-2013

A and C, Age standardized to 2000 US standard population. B and D, Incidence ratio between consecutive years; 2006 vs 2005, 2007 vs 2006, 2008 vs 2007, 2009 vs 2008, 2010 vs 2009, 2011 vs 2010, 2012 vs 2011, 2013 vs 2012. Displayed on the log-scale. Error bars depict 99% confidence intervals.

Figure 2.
Delay-Adjusted Incidence (per 100 000 Men) and Incidence Ratio for Distant Prostate Cancer by Age Group, Surveillance, Epidemiology, and End Results 18, 2005-2013
Delay-Adjusted Incidence (per 100 000 Men) and Incidence Ratio for Distant Prostate Cancer by Age Group, Surveillance, Epidemiology, and End Results 18, 2005-2013

A and C, Age standardized to 2000 US Standard Population. B and D, Incidence ratio between consecutive years; 2006 vs 2005, 2007 vs 2006, 2008 vs 2007, 2009 vs 2008, 2010 vs 2009, 2011 vs 2010, 2012 vs 2011, 2013 vs 2012. Displayed on the log-scale. Error bars depict 99% confidence intervals.

1.
Jemal  A, Fedewa  SA, Ma  J,  et al.  Prostate cancer incidence and PSA testing patterns in relation to USPSTF screening recommendations.  JAMA. 2015;314(19):2054-2061.PubMedGoogle ScholarCrossref
2.
Moyer  VA, US Preventive Services Task Force.  Screening for prostate cancer: US Preventive Services Task Force recommendation statement.  Ann Intern Med. 2012;157(2):120-134.PubMedGoogle ScholarCrossref
3.
Surveillance, Epidemiology, and End Results (SEER) Program. SEER*Stat Database: Incidence - SEER 18 Regs Research Data with Delay-Adjustment, Malignant Only, Nov 2015 Sub (2000-2013) <Katrina/Rita Population Adjustment> - Linked To County Attributes - Total US, 1969-2014 Counties, National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, released April 2016, based on the November 2015 submission. http://seer.cancer.gov/data/seerstat/nov2015/. Accessed April 11, 2016.
4.
Young  JL  Jr, Roffers  SD, Ries  LAG, Fritz  AG, Hurlbut  AA.  SEER Summary Staging Manual - 2000: Codes and Coding Instructions. Bethesda, MD: National Cancer Institute; 2001.
5.
Tiwari  RC, Clegg  LX, Zou  Z.  Efficient interval estimation for age-adjusted cancer rates.  Stat Methods Med Res. 2006;15(6):547-569.PubMedGoogle ScholarCrossref
6.
Andriole  GL, Bostwick  DG, Brawley  OW,  et al; REDUCE Study Group.  Effect of dutasteride on the risk of prostate cancer.  N Engl J Med. 2010;362(13):1192-1202.PubMedGoogle ScholarCrossref
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    1 Comment for this article
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    Effects of USPSTF Recommendations Against Prostate Cancer Screening
    Stephen B. Strum | Medical Oncologist Specializing in Prostate Cancer
    The research letter by Jemal et al is a clear-cut presentation indicating falling incidence rates of early stage prostate cancer (PC) in both younger and older men in chronological relationship to the USPSTF publication in 2012 (Jemal A, Ma J, Siegel R, et al: Prostate Cancer Incidence Rates 2 Years After the US Preventive Services Task Force Recommendations Against Screening. JAMA Oncol, 2016.) Whether or not these observations will impact the diagnosis of advanced stage PC will take additional years of follow-up.

    What concerns me as a medical oncologist that has focused on PC in the pre-PSA and post-PSA
    eras is the confusion between the value of an early diagnosis of malignancy versus the adverse outcomes affecting many of those diagnosed with PC. In my 33 years of experience consulting with men with PC from virtually every state and also other countries, these adverse outcomes relate to biopsy-associated infection and/or bleeding, & complications of surgical, radiation, or medical management of a significant percentage of these men. The underlying causes of such adverse effects are due to iatrogenic causes such as 1) poor technical biopsy skill, 2) poor clinical judgment resulting in overly aggressive treatment, and 3) human frailties involving misplaced motivations that are too distasteful to describe in detail.

    But what is missed in not making an earlier diagnosis is partly evidenced with the recent focus on so-called \"surveillance\". When a diagnosis of PC is associated with the recognition that many internal medicine issues are linked to PC, then the overall health of these men, diagnosed but not treated for PC, is greatly enhanced. Such interactive diseases include, but are not limited to bone loss, glucose intolerance, lipidemias, arteriosclerotic cardiovascular disease, obesity, inflammation, gonadal dysfunction, and secondary malignancies. The challenge that all of the above represents is how do we maximize the positive that we can do for such patients and minimize the negative? Educating the lay population, stricter guidelines for diagnosis and treatment-related procedures, changing the incentive from procedure-based to outcome-based, and perhaps creating an oncology specialty that is focused on this very problem i.e. distinguishing science from art and the lack of either are considerations. We did face a similar problem with breast cancer patients where woman were routinely being subjected to radical mastectomies, and this was dramatically changed via education and legislation. This just has not happened with men with PC.
    CONFLICT OF INTEREST: None Reported
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    Research Letter
    December 2016

    Prostate Cancer Incidence Rates 2 Years After the US Preventive Services Task Force Recommendations Against Screening

    Author Affiliations
    • 1Surveillance and Health Services Research, American Cancer Society, Atlanta, Georgia
    • 2Office of Chief Medical Officer/Research, American Cancer Society, Atlanta, Georgia
    • 3Intramural Research, American Cancer Society, Atlanta, Georgia
     

    Copyright 2016 American Medical Association. All Rights Reserved.

    JAMA Oncol. 2016;2(12):1657-1660. doi:10.1001/jamaoncol.2016.2667

    We previously reported a substantial decline in early-stage prostate cancer incidence rates from 2011 to 2012 in men 50 years or older residing in areas covered by the population-based Surveillance, Epidemiology, and End Results (SEER) program.1 This pattern coincided with the decline in prostate-specific antigen (PSA) testing in this age group between 2010 and 2013 following the US Preventive Services Task Force recommendation against routine PSA testing in all men in October 2011 in draft form and in May 2012 in final form, which was preceded by a 2008 recommendation against PSA testing in men 75 years or older.2 Whether the decrease in incidence rates persisted through 2013 is unknown.

    Methods

    The study was based on a deidentified publicly available database and did not require institutional review board review. We obtained incidence data for invasive prostate cancer diagnosed from 2005 through 2013 in men 50 years and older in 18 SEER registries, covering approximately 28% of the US population.3 Cases were categorized as local/regional or distant stage according to SEER summary stage.4(p226) We calculated delay-adjusted incidence rates by age (≥50 years, 50-74, ≥75 years), stage (all stages, local/regional, distant), and race/ethnicity (all races, non-Hispanic whites, non-Hispanic blacks) using SEER*Stat software.3 Rates were age standardized to the 2000 US population and expressed per 100 000 men. Incidence ratios (IRs) and their 99% confidence intervals measuring the relative change in incidence rates between consecutive years (eg, 2005 vs 2006) were calculated using the method of Tiwari et al.5

    Results

    From 2012 to 2013, localized/regional-stage prostate cancer incidence rates per 100 000 men significantly decreased from 356.5 to 335.4 (IR, 0.94; 99% CI, 0.92-0.96) in men aged 50 to 74 years and from 379.2 to 353.6 (IR, 0.93; 99% CI, 0.89-0.97) in men aged 75 years and older (Figure 1). In contrast, incidence rates for distant-stage disease during the corresponding period remained unchanged in both men aged 50 to 74 years (from 15.7 to 16.5; IR, 1.05; 99% CI, 0.96-1.15) and 75 years and older (from 65.8 to 66.4; IR, 1.01; 99% CI, 0.91-1.12) (Figure 2). We found similar results in non-Hispanic whites and non-Hispanic blacks, although the decrease for early-stage disease in blacks was not statically significant, possibly due to lack of statistical power (data not shown).

    Discussion

    Incidence rates for early-stage prostate cancer continued to decline in men 50 years and older in the 18 SEER areas following the US Preventive Services Task Force recommendations against routine PSA testing to all men in 2012, although the decrease from 2012 to 2013 was smaller than that from 2011 to 2012 (6% vs 19%). Simultaneously, as reported before, PSA testing rates between 2010 and 2013 in the United States significantly decreased from 36.8% (99% CI, 34.3%-39.4%) to 29.9% (99% CI, 28.0%-32.0%) in men 50 to 74 years old and from 43.1% (99% CI, 37.1%-49.2%) to 36.3% (99% CI, 31.1%-41.9%) in men 75 years and older.1

    Other factors that may have contributed to the decrease in incidence rates for early-stage prostate cancer include changes in the prevalence of risk factors and/or preventive measures. However, as noted in our previous article,1 temporal changes in established risk factors (age, race/ethnicity, and family history) are unlikely to have caused the continued decrease in the incidence rates. Although 5α-reductase inhibitor treatment has been shown to reduce the risk of prostate cancer,6 their use is not recommended for prevention in the general population.

    In conclusion, the decrease in early-stage prostate cancer incidence rates from 2011 to 2012 in men 50 years and older persisted through 2013 in SEER registries, albeit at a slower pace. Whether this pattern will lead to a future increase in the diagnosis of distant-stage disease and prostate cancer mortality requires long-term monitoring because of the slow-growing nature of this malignant neoplasm.

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    Article Information

    Corresponding Author: Ahmedin Jemal, DVM, PhD, Surveillance and Health Services Research, American Cancer Society, 250 Williams St NW, Atlanta, GA 30345 (ajemal@cancer.org).

    Published Online: August 18, 2016. doi:10.1001/jamaoncol.2016.2667

    Author Contributions: Dr Ma had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: Jemal, Brawley, Ward.

    Acquisition, analysis, or interpretation of data: Jemal, Ma, Siegel, Fedewa.

    Drafting of the manuscript: Jemal.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Ma.

    Administrative, technical, or material support: Jemal, Fedewa, Brawley.

    Study supervision: Jemal, Brawley, Ward.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This project was supported by the Intramural Research Department of the American Cancer Society.

    Role of the Funder/Sponsor: The American Cancer Society had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The opinions expressed are solely the responsibility of the authors and do not necessarily reflect the official views of the American Cancer Society.

    References
    1.
    Jemal  A, Fedewa  SA, Ma  J,  et al.  Prostate cancer incidence and PSA testing patterns in relation to USPSTF screening recommendations.  JAMA. 2015;314(19):2054-2061.PubMedGoogle ScholarCrossref
    2.
    Moyer  VA, US Preventive Services Task Force.  Screening for prostate cancer: US Preventive Services Task Force recommendation statement.  Ann Intern Med. 2012;157(2):120-134.PubMedGoogle ScholarCrossref
    3.
    Surveillance, Epidemiology, and End Results (SEER) Program. SEER*Stat Database: Incidence - SEER 18 Regs Research Data with Delay-Adjustment, Malignant Only, Nov 2015 Sub (2000-2013) <Katrina/Rita Population Adjustment> - Linked To County Attributes - Total US, 1969-2014 Counties, National Cancer Institute, DCCPS, Surveillance Research Program, Surveillance Systems Branch, released April 2016, based on the November 2015 submission. http://seer.cancer.gov/data/seerstat/nov2015/. Accessed April 11, 2016.
    4.
    Young  JL  Jr, Roffers  SD, Ries  LAG, Fritz  AG, Hurlbut  AA.  SEER Summary Staging Manual - 2000: Codes and Coding Instructions. Bethesda, MD: National Cancer Institute; 2001.
    5.
    Tiwari  RC, Clegg  LX, Zou  Z.  Efficient interval estimation for age-adjusted cancer rates.  Stat Methods Med Res. 2006;15(6):547-569.PubMedGoogle ScholarCrossref
    6.
    Andriole  GL, Bostwick  DG, Brawley  OW,  et al; REDUCE Study Group.  Effect of dutasteride on the risk of prostate cancer.  N Engl J Med. 2010;362(13):1192-1202.PubMedGoogle ScholarCrossref
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