Prostate cancer diagnoses have been rising in recent years, with a sharp increase in cases diagnosed at advanced stages, when it is harder to treat, according to a new report by the American Cancer Society. Many experts attributed the increase to a guideline change made over a decade ago that discouraged routine screening for the common cancer.
The new analysis also highlighted racial disparities that have persisted, despite overall declines in mortality. Black men develop prostate cancer at significantly higher rates than white men and die at twice the rate of white men. Native Americans die at higher rates although they have a lower incidence of the disease.
The report, published on Tuesday in the medical journal CA: A Cancer Journal for Clinicians, underscores the challenge of finding the right balance in cancer screening: Screen too much and you may end up causing harm by aggressively treating indolent disease that will never be life-threatening; screen too little and you may miss deadly disease.
Dr. Bill Dahut, chief scientific officer for the American Cancer Society and one of the authors of the new report, tied a recommendation by a national task force to pull back on routine prostate cancer screening to the rise in the diagnosis of more advanced cancers.
“The pendulum may have swung too far in one direction, where we were afraid of overtreatment,” Dr. Dahut said, “and now we’re not finding these cancers early on, when they can be treated and are more curable, and we’re more likely to find metastatic disease that is not curable.”
In 2012, the U.S. Preventive Services Task Force, which makes recommendations for preventive health care services in the United States, started discouraging routine administration of the blood tests that are used to screen healthy men for prostate cancer.
The idea was to reduce the harmful treatment of harmless disease, which in the case of prostate cancer can lead to life-altering side effects, like incontinence and impotence. The task force relied heavily on a study that had found that screening made little difference in survival rates. Critics have since found flaws in that study, and other studies have found opposite results.
In 2018, the task force said screening should be an individual decision for men 55 to 69 and should stop altogether at 70. The latter recommendation has given many doctors pause, now that men are living longer and could benefit from treatment even if they are in their 70s.
Former President Joseph R. Biden Jr. in May received a diagnosis of an aggressive form of prostate cancer that had spread to his bones. He last received the screening test in 2014, which was in line with the 2012 medical guidelines.
Those guidelines are in the process of being updated by the U.S. Preventive Services Task Force. In July, however, the Health and Human Services secretary, Robert F. Kennedy Jr., abruptly canceled a meeting of the task force, raising questions about its future.
Many experts in the field say that reducing routine screening may have inadvertently led to a bump in severe disease.
“It’s not easy to link a specific guideline to a worsening of disease, but it’s fairly convincing that the U.S. Preventive Services Task Force’s 2012 recommendations were very harmful,” said Dr. Jonathan S. Fainberg, a urologic surgeon at Memorial Sloan Kettering Cancer Center in New York who was not involved in the new report.
“The time frame makes perfect sense for when P.S.A. screening was not recommended,” Dr. Fainberg said, referring to the screening test that detects high levels of the prostate-specific antigen in the blood that can be an indication of prostate cancer, though it may be elevated in other, benign, conditions as well.
“We know P.S.A. tends to catch prostate cancer half a decade before there is a nodule I can feel or bone pain from metastatic disease,” he said.
From 2007 to 2014, new diagnoses of prostate cancer declined by 6.4 percent a year, but in 2014, the rates of diagnosis started climbing by 3 percent a year, with diagnoses of advanced-stage disease increasing by 4.6 percent to 4.8 percent each year from 2017 to 2021, while diagnoses of localized disease dropped.
Prostate cancer is the most common cancer affecting men, making up almost one-third of the cancers diagnosed. It is the second leading cause of cancer death for men after lung cancer. Some 313,780 cases of prostate cancer are expected to be diagnosed in the United States this year, and about 35,770 men will die of it.
Experts said they could not rule out the possibility that other factors, like environmental exposures, may have contributed to the rise in advanced cases. Several other cancers, including colorectal cancer and breast cancer, have been inching up in younger adults, for reasons that are not clear.
Improved imaging scans that can better detect cancers that have spread outside the prostate may also have led to more diagnoses of advanced-stage disease, the experts said.
The new study found increases in men of all ages of so-called distant-stage disease, meaning the disease has spread outside the prostate gland to distant parts of the body. Rates of distant-stage disease increased nearly 3 percent a year in men younger than 55, and increased by 6 percent a year for men over 55. Distant-stage disease has a lower five-year survival rate than cancers diagnosed at an earlier stage.
Among men 55 to 69, the rates of diagnoses of regional disease, which has spread outside the prostate to regional tissue, also increased, the new study found.
And while mortality rates continued to decline, the rate of decline has plateaued over the past decade to less than 1 percent a year, despite the development of new and powerful drugs, the report found.
Prostate cancer mortality varies by state, with the highest death rates in Washington, D.C., and Mississippi, both of which have a high proportion of Black residents, the study said. Black men have a 67 percent higher incidence of the cancer compared with white men, but they are twice as likely to die.
The reasons for the racial disparities include unequal access to quality care: A study of prostate cancer patients who were treated at the Department of Veterans Affairs, where patients have equal access to care, found that Black men did not appear to have more aggressive cancers at diagnosis and that they had slightly higher survival rates.
The American Cancer Society recommends that all men discuss prostate cancer screening with their doctors when they are 50, but it urges Black men and anyone with a family history of prostate cancer to have that conversation at 45.
Male carriers of the BRCA2 gene mutation, which is associated with breast and ovarian cancer, are at a high relative risk of developing prostate cancer. Some specialty societies recommend that Black men and those at higher than average risk should have a base-line P.S.A. blood test between ages 40 and 45.
Dr. William K. Oh, director of precision medicine at Yale Cancer Center, suggested that current screening recommendations should be re-evaluated.
“Have we abandoned a good strategy, the P.S.A. strategy, and thrown the baby out with the bath water? That is my concern,” Dr. Oh said. “The reason death rates were going down was because we were finding prostate cancer earlier and earlier.”
Roni Caryn Rabin is a Times health reporter focused on maternal and child health, racial and economic disparities in health care, and the influence of money on medicine.
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