Overdiagnosis due to prostate-specific antigen screening: lessons from U.S. prostate cancer incidence trends

BACKGROUND: Overdiagnosis of clinically insignificant prostate cancer is considered a major potential drawback of prostate-specific antigen (PSA) screening. Quantitative estimates of the magnitude of this problem are, however, lacking. We estimated rates of prostate cancer overdiagnosis due to PSA testing that are consistent with the observed incidence of prostate cancer in the United States from 1988 through 1998. Overdiagnosis was defined as the detection of prostate cancer through PSA testing that otherwise would not have been diagnosed within the patient's lifetime. METHODS: We developed a computer simulation model of PSA testing and subsequent prostate cancer diagnosis and death from prostate cancer among a hypothetical cohort of two million men who were 60-84 years old in 1988. Given values for the expected lead time--that is, the time by which the test advanced diagnosis--and the expected incidence of prostate cancer in the absence of PSA testing, the model projected the increase in population incidence of prostate cancer associated with PSA testing. By comparing the model-projected incidence with the observed incidence derived from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry data, we determined the lead times and corresponding overdiagnosis rates that were consistent with the observed data. RESULTS: SEER data on prostate cancer incidence from 1988 through 1998 were consistent with overdiagnosis rates of approximately 29% for whites and 44% for blacks among men with prostate cancers detected by PSA screening. CONCLUSIONS: Among men with prostate cancer that would be detected only at autopsy, these rates correspond to overdiagnosis rates of, at most, 15% in whites and 37% in blacks. The observed trends in prostate cancer incidence are consistent with considerable overdiagnosis among PSA-detected cases. However, the results suggest that the majority of screen-detected cancers diagnosed between 1988 and 1998 would have presented clinically and that only a minority of cases found at autopsy would have been detected by PSA testing.     

Cancer surveillance series: interpreting trends in prostate cancer--part II: Cause of death misclassification and the recent rise and fall in prostate cancer mortality.

BACKGROUND: The rise and fall of prostate cancer mortality correspond closely to the rise and fall of newly diagnosed cases. To understand this phenomenon, we explored the role that screening, treatment, iatrogenic (i.e., treatment-induced) deaths, and attribution bias (incorrect labeling of death from other causes as death from prostate cancer) have played in recent mortality trends. METHODS: Join point regression is utilized to assess the recent rise and fall in mortality and the relationship of total U.S. trends to those areas served by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Cancer Registry Program. Incidence-based mortality (IBM) is estimated with the use of prostate cancer data from the SEER Program to partition (from overall prostate cancer mortality trends) the contribution of cases diagnosed since the widespread use of prostate-specific antigen (PSA) testing starting in 1987. IBM is also used to examine the contribution of stage at diagnosis to the recent prostate cancer mortality trends. RESULTS: IBM for cases diagnosed since 1987 rose above the pre-1987 secular (i.e., background) trend, peaked in the early 1990s, and almost returned to the secular trend by 1994. This rise and fall of IBM track with the pool of prevalent cases diagnosed within the prior 2 years. IBM for cases diagnosed with metastatic disease fell starting in 1991, while IBM for those diagnosed with localized/regional disease was relatively flat. CONCLUSIONS: The rise and fall in prostate cancer mortality observed since the introduction of PSA testing in the general population are consistent with a hypothesis that a fixed percent of the rising and falling pool of recently diagnosed patients who die of other causes may be mislabeled as dying of prostate cancer. The decline in IBM for distant stage disease and flat IBM trends for localized/regional disease provide some evidence of improved prognosis for screen-detected cases, although alternative interpretations are possible.     

Interpreting trends in prostate cancer incidence and mortality in the five Nordic countries

Trends in incidence and mortality rates of prostate cancer were analyzed using data from the national cancer registries of Denmark, Finland, Iceland, Norway, and Sweden. Joinpoint regression models were used to quantify temporal trends for the period from 1980 to 2004. Incidence rates were increasing and similar in the Nordic countries during the 1980s. Around 1990, a more rapid incidence increase began in all Nordic countries except Denmark, where an increase was seen 5 years later. In 2001, incidence rates in Denmark were half of those seen in the other Nordic countries, but mortality rates varied only marginally among countries. Mean annual declines in prostate cancer mortality of 1.9% (95% CI = 0.4% to 3.3%) and 1.8% (95% CI = 0.5% to 3.0%) were observed from 1996 to 2004 in Finland and Norway, respectively. During the same period, mortality rates leveled off in Iceland and Sweden but continued to increase in Denmark. The rapid increase in incidence during the early 1990s coincided with the introduction of the prostate-specific antigen (PSA) test and conveys little information about the occurrence of potentially lethal disease. Mortality rates, however, have recently stabilized or declined in countries where PSA testing and curative treatment have been commonly practiced since the late 1980s. Although other explanatory factors may be in operation, these trends are consistent with a moderate effect of increased curative treatment of early diagnosed prostate cancer and improved treatment of more advanced disease.     

Prostate cancer: Trends in incidence,survival and mortality in the Netherlands, 1989–2006

BackgroundProstate cancer occurrence and stage distribution changed dramatically during the end of the 20th century. This study aimed to quantify and explain trends in incidence, stage distribution, survival and mortality in the Netherlands between 1989 and 2006.MethodsPopulation-based data from the nationwide Netherlands Cancer Registry and Causes of Death Registry were used. Annual incidence and mortality rates were calculated and age-adjusted to the European Standard Population. Trends in rates were evaluated by age, clinical stage and differentiation grade.Results120,965 men were newly diagnosed with prostate cancer between 1989 and 2006. Age-adjusted incidence rates increased from 63 to 104 per 100,000 person-years in this period. Two periods of increasing incidence rates could be distinguished with increases predominantly in cT2-tumours between 1989 and 1995 and predominantly in cT1c-tumours since 2001. cT4/N+/M+-tumour incidence rates decreased from 23 in 1993 to 18 in 2006. The trend towards earlier detection was accompanied by a lower mean age at diagnosis (from 74 in 1989 to 70 in 2006), increased frequency of treatment with curative intent and improved 5-year relative survival. Mortality rates decreased from 34 in 1996 to 26 in 2007.ConclusionsThe increase of prostate cancer incidence in the early 1990s was probably caused by increased prostate cancer awareness combined with diagnostic improvements (transrectal ultrasound, (thin) needle biopsies), but not PSA testing. The subsequent peak since 2001 is probably attributable to PSA testing. The decline in prostate cancer mortality from 1996 onwards may be the consequence of increased detection of cT2-tumours between 1989 and 1995. Unfortunately, data on the use of PSA tests and other prostate cancer diagnostics to support these conclusions are lacking.     

Prostate cancer mortality in Connecticut, Iowa and New Mexico African American men

We sought to assess trends in prostate cancer incidence, treatment and mortality in African American men by means of analysis of prostate cancer data from three states, Connecticut, Iowa and New Mexico, all participants in the Surveillance, Epidemiology, and End Results (SEER) Program. Compared with levels before prostate specific antigen (PSA) testing, prostate cancer incidence increased in all three states after widespread testing. For men diagnosed with localized or regional prostate cancer, the respective increases in radical prostatectomy in Connecticut, Iowa, and New Mexico were 3.2, 2.3, and 4.9 times pre-test levels. Age-standardized mortality in Connecticut and Iowa increased slightly; in New Mexico the 104.7 deaths per 100,000 in 1979-1986, 62.1 in 1987-1990, dropped to 47.6 in 1991-1998, an amount of decline that was statistically significant. Introduction of PSA testing influenced early detection and treatment of prostate cancer in all three states. Although decline in prostate cancer mortality in New Mexico over time may be linked with use of the PSA test and definitive therapy, the relationship among these factors, and thus the proper treatment for the early stages of this condition, is unclear on the basis of these data.     

Determination of county-level prostate carcinoma incidence and detection rates with Medicare claims data.

BACKGROUND: To the authors' knowledge, national-level population-based data regarding prostate carcinoma incidence and detection currently are not available. The availability of such data could identify those regions with a disproportionately high cancer incidence as well as the population-level association between prostate carcinoma detection and incidence. METHODS: Inpatient, hospital outpatient, and physician/supplier Medicare claims from 1997 were used to identify incident cases of prostate carcinoma in men age > or = 65 years and to calculate state and county-level incidence rates. The 1991 and 1997 claims data were used to determine small area rates of prostate-specific antigen (PSA) testing and prostate biopsy and to determine their correlation with incidence. RESULTS: The calculated incidence rates for 1997 were 890 per 100,000 and 1196 per 100,000, respectively, in white males and African-American males and varied substantially between counties (i.e., 25--75th percentile, 676--1124 per 100,000). Rates of PSA and prostate biopsy increased markedly from 1991 to 1997 in both white men (1580 per 100,000 to 24,286 per 100,000) and African-American men (1277 per 100,000 to 15,190 per 100,000), and considerable variation in detection between counties was observed. Counties that had higher rates of prostate biopsy also had higher age-adjusted incidence rates, and county-level PSA testing was found to be associated with incidence in African-American patients, but not in white patients. CONCLUSIONS: Medicare claims may provide an alternative source of population-based data, particularly for areas in which registry data are not readily available or are of limited scope. In addition, claims provide otherwise unavailable national data concerning cancer detection.     

Prostate cancer incidence in 43 populations worldwide: An analysis of time trends overall and by age group

Prostate cancer is a significant public health burden and a major cause of morbidity and mortality among men worldwide. Analyzing geographic patterns and temporal trends may help identify high‐risk populations, suggest the degree of PSA testing, and provide clues to etiology. We used incidence data available from the International Agency for Research on Cancer (IARC) and certain cancer registries for 43 populations across five continents during a median period of 24 years. Trends in overall prostate cancer rates showed five distinct patterns ranging from generally monotonic increases to peaking of rates followed by declines, which coincide somewhat with changes in the prevalence of PSA testing. Trends in age‐specific rates generally mirrored those in the overall rates, with several notable exceptions. For populations where overall rates increased rapidly and then peaked, exemplified in North America and Oceania, the highest incidence tended to be most pronounced and occurred during earlier calendar years among older men compared with younger ones. For populations with almost continual increases in overall rates, exemplified in Eastern Europe and Asia, peaks were evident among men aged ≥75 years in many instances. Rates for ages 45–54 years did not clearly stabilize or decline in the majority of studied populations. Global geographic variation remained substantial for both overall and age‐specific incidence rates regardless of levels of PSA testing, with the lowest rates consistently in Asia. Explanations for the persistent geographic differences and the continuing increases of especially early‐onset prostate cancer remain unclear.     

Prostate cancer incidence, mortality, and survival trends in the United States: 1981-2001

The increased use of prostate-specific antigen (PSA) in screening for preclinical disease after 1985 is thought to be a major determinant of the changing patterns in prostate cancer incidence; however, the long-term effect of screening on future trends in mortality and survival is uncertain. This article reviews the temporal trends (1981-1998) for prostate cancer incidence, mortality, and survival, and projects prostate cancer incidence and mortality rates for 1999 to 2001. Autoregressive, quadratic, time-series models were used to describe prostate cancer mortality rates in the US population and prostate cancer incidence rates derived from the National Cancer Institute's (NCI) Surveillance, Epidemiology and End Results (SEER) program. These models were based on data collected from 1979 through 1998, with forecasts produced for 1999 to 2001. Prostate cancer incidence increased steadily from 1981 to 1989, with a steep increase in the early 1990s, followed by a decline. Incidence rates were forecasted to remain stable through the year 2001. Mortality rates decreased steadily and were forecasted to continue to decrease concurrently with increasing 5- and 10-year relative survival rates. The incidence, mortality, and survival trends were comparable in US blacks, who exhibited on average 2-fold higher mortality and 50% higher incidence than whites. Decreasing prostate cancer mortality and increasing relative survival trends in the United States were described after the introduction of PSA screening. However, the exaggerated rate of increase in the early 1990s in prostate cancer incidence was transient and likely a result of increased detection of preclinical disease that was prevalent in the general population.     

A comparative population-based study of prostate cancer incidence and mortality rates in Singapore, Sweden and Geneva, Switzerland from 1968 to 2006

ABSTRACT: BACKGROUND: Prostate cancer is the most commonly diagnosed malignancy in men in Sweden and Geneva, and the third most common in men in Singapore. This population-based study describes trends in the incidence and mortality rates of prostate cancer in Singapore, Sweden and Geneva (Switzerland) from 1973 to 2006 and explores possible explanations for these different trends. METHODS: Data from patients diagnosed with prostate cancer were extracted from national cancer registries in Singapore (n?=?5,172), Sweden (n?=?188,783) and Geneva (n?=?5,755) from 1973 to 2006. Trends of incidence and mortality were reported using the Poisson and negative binomial regression models. The age, period and birth-cohort were tested as predictors of incidence and mortality rates of prostate cancer. RESULTS: Incidence rates of prostate cancer increased over all time periods for all three populations. Based on the age-period-cohort analysis, older age and later period of diagnosis were associated with a higher incidence of prostate cancer, whereas older age and earlier period were associated with higher mortality rates for prostate cancer in all three countries. CONCLUSIONS: This study demonstrated an overall increase in incidence rates and decrease in mortality rates in Singapore, Sweden and Geneva. Both incidence and mortality rates were much lower in Singapore. The period effect is a stronger predictor of incidence and mortality of prostate cancer than the birth-cohort effect.     

Trends in prostate cancer mortality among black men and white men in the United States

BACKGROUND: Prostate cancer mortality rates in the United States declined sharply after 1991 in white men and declined after 1992 in black men. The current study was conducted to investigate possible mechanisms for the declining prostate cancer mortality rates in the United States. METHODS: The authors examined and compared patterns of prostate cancer incidence, survival rates, and mortality rates among black men and white men in the United States using the 1969-1999 U.S. prostate cancer mortality rates and the 1975-1999 prostate cancer incidence, survival, and incidence-based mortality rates from the Surveillance, Epidemiology, and End Results (SEER) Program for the U.S. population. The SEER data represent approximately 10% of the U.S. population. RESULTS: Prostate cancer incidence and mortality rates showed transient increases after 1986, when the U.S. Food and Drug Administration approved the use of prostate specific antigen (PSA) testing. The age-adjusted prostate cancer mortality rates for men age 50-84 years, however, have dropped below the rate in 1986 since 1995 for white men and since 1997 for black men. In fact, for white men ages 50-79 years, the 1998 and 1999 rates were the lowest observed since 1950. Incidence-based mortality rates by disease stage revealed that the recent declines were due to declines in distant disease mortality. Moreover, the decrease in distant disease mortality was due to a decline in distant disease incidence, and not to improved survival of patients with distant disease. CONCLUSIONS: Similar incidence, survival, and mortality rate patterns are seen in black men and white men in the United States, although with differences in the timing and magnitude of recent rate decreases. Increased detection of prostate cancer before it becomes metastatic, possibly reflecting increased use of PSA testing after 1986, may explain much of the recent mortality decrease in both white men and black men.     

Changing relationship between socioeconomic status and prostate cancer incidence

BACKGROUND: Understanding the relationship between socioeconomic status (SES) and prostate cancer incidence could identify populations that should be targeted for intervention and prevention programs. We examined this relationship within the major racial/ethnic groups during the period 1972 through 1997, which spans the introduction of prostate-specific antigen (PSA) testing. METHODS: We used data from the population-based Los Angeles Cancer Surveillance Program to examine age-adjusted prostate cancer incidence rates in five SES groups over three specific calendar periods by racial/ethnic subpopulation (white, black, Asian, and Hispanic) and by stage of disease at diagnosis. Linear regression analysis was used to test for trends in the age-adjusted incidence rates that were associated with increasing levels of SES. All P values were two-sided. RESULTS: For men diagnosed with prostate cancer before 1987, when the test for PSA was not widely available, we found no association between SES and the incidence of prostate cancer in any of four racial/ethnic subpopulations or between SES and the stage of disease at diagnosis. In contrast, among men who were diagnosed with prostate cancer after 1987, SES was statistically significantly and positively associated with prostate cancer incidence in men from all racial/ethnic subpopulations except Asians (P =.01 for white men, P =.001 for black men, P =.02 for Hispanic men, P =.06 for Asian men, and P =.01 for all men combined). Higher SES was statistically significantly associated with cancers of earlier stage (P =.01 for localized cancer and P =.00 for regional cancer) for men who were diagnosed with prostate cancer after 1987. CONCLUSIONS: The association between SES and prostate cancer incidence after 1987 may reflect more prevalent PSA screening in populations with higher SES due to their greater access to health care. SES should, therefore, be considered an important factor in interpreting variations and time trends in prostate cancer incidence.     

Reconstructing PSA testing patterns between black and white men in the US from Medicare claims and the National Health Interview Survey

BACKGROUND: Frequencies of prostate-specific antigen (PSA) test administration were not actively monitored on a national level during the first decade of PSA testing. The objectives of this article were to reconstruct patterns of PSA testing between black and white men in the US and to determine the extent of any racial disparity in PSA use. METHODS: Data from the 2000 National Health Interview Survey were used to model the adoption of PSA and to estimate the distribution of age at first test. Longitudinal Medicare claims data were used to estimate the distribution of intervals between tests. The rates of initial and subsequent tests were then combined by simulation to reconstruct individual screening histories. Results are from the reconstructed model. RESULTS: Overall, 45% of white men and 43% of black men within ages 40-84 years had at least 1 PSA test by the year 2000. The authors found that among older men, whites adopted PSA screening earlier than blacks, whereas among younger men, this trend was reversed, with blacks adopting screening earlier than whites. Annual testing frequencies generated by the simulation model were higher for white men aged>or=60 years and higher for black men aged<60 years. CONCLUSIONS: Findings indicated fairly similar patterns overall of PSA testing for blacks and whites. These similarities indicated that racial disparity in PSA testing is probably not a major factor behind current racial differences in prostate cancer mortality rates and declines. Knowledge of patterns of screening is important to an understanding of the impact of population screening on cancer incidence and mortality, but retrospective data sources have significant limitations when used to estimate these patterns of care.     

Excess cases of prostate cancer and estimated overdiagnosis associated with PSA testing in East Anglia

This study aimed to estimate the extent of 'overdiagnosis' of prostate cancer attributable to prostate-specific antigen (PSA) testing in the Cambridge area between 1996 and 2002. Overdiagnosis was defined conceptually as detection of prostate cancer through PSA testing that otherwise would not have been diagnosed within the patient's lifetime. Records of PSA tests in Addenbrookes Hospital were linked to prostate cancer registrations by NHS number. Differences in prostate cancer registration rates between those receiving and not receiving prediagnosis PSA tests were calculated. The proportion of men aged 40 years or over with a prediagnosis PSA test increased from 1.4 to 5.2% from 1996 to 2002. The rate of diagnosis of prostate cancer was 45% higher (rate ratios (RR)=1.45, 95% confidence intervals (CI) 1.02-2.07) in men with a history of prediagnosis PSA testing. Assuming average lead times of 5-10 years, 40-98% [corrected] of the PSA-detected cases were estimated to be overdiagnosed. In East Anglia, from 1996 to 2000, a 1.6% excess of cases was associated with PSA testing (around a quarter of the 5.3% excess incidence cases observed in East Anglia from 1996 to 2000). Further quantification of the overdiagnosis will result from continued surveillance and from linkage of incidence to testing in other hospitals.     

International trends in prostate-cancer mortality in the "PSA ERA"

Incidence and mortality from prostate cancer were rising in most countries until the late 1980s. Following a number of advances in the management of prostate cancer, including introduction of the prostate-specific antigen (PSA) test, there have been reports of declines in mortality in Canada, the United States and the United Kingdom. To investigate the extent to which this pattern was seen in other industrialised countries, we used routinely collected data to explore recent changes in prostate-cancer mortality. Trends in age-standardised death rates between 1979 and 1997 for men aged 50 to 79 years in 24 industrialised countries were compared using join point regression. Join point regression allows estimation of the annual percentage change in death rates and tests for significant changes in trend. During the period studied, age-standardised mortality increased at 1% to 2% per year in most countries. In 7 countries (Canada, United States, Austria, France, Germany, Italy and United Kingdom), a significant down-turn in age-standardised mortality was observed over the period 1988-1991. Trends in age-specific rates within these countries support a period effect on prostate-cancer mortality. Declines in mortality could result from any combination of either artefact, reduction in prostate-cancer incidence, a rise in competing causes of death or changes in the risk of death from prostate cancer. There are inconsistencies in the relationship between national mortality trends and uptake of PSA screening; further research is required to determine whether changes in death rates can be explained by international and secular variations in the treatment of prostate cancer.     

Impact of PSA testing and prostatic biopsy on cancer incidence and mortality: comparative study between the Republic of Ireland and Northern Ireland

Objectives

To investigate the impact of different PSA testing policies and health-care systems on prostate cancer incidence and mortality in two countries with similar populations, the Republic of Ireland (RoI) and Northern Ireland (NI).

Methods

Population-level data on PSA tests, prostate biopsies and prostate cancer cases 1993–2005 and prostate cancer deaths 1979–2006 were compiled. Annual percentage change (APC) was estimated by joinpoint regression.

Results

Prostate cancer rates were similar in both areas in 1994 but increased rapidly in RoI compared to NI. The PSA testing rate increased sharply in RoI (APC = +23.3%), and to a lesser degree in NI (APC = +9.7%) to reach 412 and 177 tests per 1,000 men in 2004, respectively. Prostatic biopsy rates rose in both countries, but were twofold higher in RoI. Cancer incidence rates rose significantly, mirroring biopsy trends, in both countries reaching 440 per 100,000 men in RoI in 2004 compared to 294 in NI. Median age at diagnosis was lower in RoI (71 years) compared to NI (73 years) (p < 0.01) and decreased significantly over time in both countries. Mortality rates declined from 1995 in both countries (APC = ?1.5% in RoI, ?1.3% in NI) at a time when PSA testing was not widespread.

Conclusions

Prostatic biopsy rates, rather than PSA testing per se, were the main driver of prostate cancer incidence. Because mortality decreases started before screening became widespread in RoI, and mortality remained low in NI, PSA testing is unlikely to be the explanation for declining mortality.     

Prostate cancer in Saskatchewan Canada, before and during the PSA era

Objectives: The purpose of this study was to describe changes in the incidence of prostate cancer and in survival of diagnosed cases, as well as prostate cancer-specific mortality, during a period spanning the introduction of prostate specific antigen (PSA) testing in Saskatchewan in 1990.Methods: All cases of neoplasms of the prostate (ICD-O = C61.9) diagnosed in Saskatchewan from 1970 to 1997 inclusive, were identified in the Saskatchewan Cancer Registry. A subgroup of adenocarcinomas was defined for further study. Age-adjusted and age-specific incidence rates, and actuarial and relative survival were calculated according to time period of diagnosis. Age-adjusted and age-specific mortality rates from prostate cancer were also calculated for each time period, using Vital Statistics data.Results: The age-adjusted incidence of prostate cancer was 60.5 per 10⁵ in 1970, rising gradually to 101.5 per 10⁵ in 1989. In 1990, incidence rose much more sharply, reaching a peak of 163.1 per 10⁵in 1993, after which it began to fall. This sharp increase coincided with the introduction and increasing use of the PSA test in the province. Relative survival of prostate cancer patients was stable from the late 1970s through the 1980s, then improved markedly in the 1990–94 period. After the introduction of the PSA test, the relative risk of death for prostate cancer patients was only about 60% of what it had been throughout the previous 15 years. Prostate cancer-specific death rates did not change from the early 1980s to the end of the study period.Conclusions: The above data are consistent with earlier diagnosis of prostate cancer due to PSA screening. Because mortality has not yet changed, it is premature to recommend widespread screening of asymptomatic men.     

Cancer rates among American Indians and Alaska Natives: is there a national perspective

BACKGROUND: Two important goals of cancer surveillance are to provide milestones in the effort to reduce the cancer burden and to generate observations that form the basis for cancer research and intervention for cancer prevention and control. Determination of the cancer burden among American Indians and Alaska Natives (AIAN) has been difficult largely due to lack of data collection efforts in many areas of the country and misclassification of racial data that results in undercounting of Native Americans. There is a revitalized commitment to improve data collection among the national agencies and organizations. METHODS: Data on cancer trends from 12 areas covered by the Surveillance, Epidemiology and End Results (SEER) Program were reviewed for incidence and death rates for 1992-2000. AIAN trends were examined and compared with trends among other racial/ethnic population groups. Reference was made to studies of disease-specific survival for nine of the SEER areas for 1988-1997. RESULTS: In SEER areas, cancer incidence rates for AIAN populations appeared to be decreasing significantly for lung and breast cancers among women and for prostate cancer among men. However, death rates rose, although not significantly, over the same period, except for a significant decrease in prostate cancer. Among the cancers with rising death rates were lung cancer (AIAN women) and colorectal cancer (AIAN men). In addition, survival often was lower for AIAN populations. CONCLUSIONS: Although the incidence was stable or decreased among AIAN populations, increased death rates and lower survival rates indicate the need for intensified application of cancer prevention and control measures, including screening and treatment. Difficulties in interpretation of data include small population size and substantial interregional differences in rates.     

Estimation of Time Trends of Incidence of Prostate Cancer – an Indian Scenario

Background: With increase in life expectancy, adoption of newer lifestyles and screening using prostatespecific antigen (PSA), the incidence of prostate cancer is on rise. Globally prostate cancer is the second mostfrequently diagnosed cancer and sixth leading cause of cancer death in men. The present communication makesan attempt to analyze the time trends in incidence for different age groups of the Indian population reportedin different Indian registries using relative difference and regression approaches. Materials and Methods: Thedata published in Cancer Incidence in Five Continents for various Indian registries for different periods and/orpublications by the individual registries served as the source materials. Trends were estimated by computing themean annual percentage change (MAPC) in the incidence rates using the relative difference between two timeperiods (latest and oldest) and also by estimation of annual percentage change (EAPC) by the Poisson regressionmodel. Results: Age adjusted incidence rates (AAR) of prostate cancer for the period 2005-2008 ranged from 0.8(Manipur state excluding Imphal west) to 10.9 (Delhi) per 105 person-years. Age specific incidence rates (ASIR)increased in all PBCRs especially after 55 years showing a peak incidence at +65 years clearly indicating thatprostate cancer is a cancer of the elderly. MAPC in crude incidence rate(CR) ranged from 0.14 (Ahmedabad)to 8.6 (Chennai) . Chennai also recorded the highest MAPC of 5.66 in ASIR in the age group of 65+. Estimatedannual percentage change (EAPC) in the AAR ranged from 0.8 to 5.8 among the three registries. Increase intrend was seen in the 5-64 year age group cohort in many registries and in the 35-44 age group in Metropolitancities such as Delhi and Mumbai. Conclusions: Several Indian registries have revealed an increasing trend inthe incidence of prostate cancer and the mean annual percentage change has ranged from 0.14-8.6.     

Prostate cancer incidence and survival in relation to education (United States)

IntroductionThere are few data on prostate cancer incidence and survival in relation to socioeconomic status in the 1990s, after the introduction of prostate specific Antigen (PSA) testing. Materials and methods: We studied the relation of education to prostate cancer incidence and survival in the Cancer Prevention Study II (CPS-II) Nutrition Cohort. Participants provided questionnaire data on diet, medical history, education, and PSA testing. We followed 72,449 men from 1992–1999 for cancer incidence (4279 incident cases), and through 2000 for survival (158 prostate cancer deaths among incident cases). Results: Multivariate-adjusted rate ratios (RRs) were calculated using Cox proportional hazards models. Self-reported (PSA) tests were more common among the more highly educated. Men with at least a college education had a 15–19 higher prostate cancer incidence than those with a high school education or less, but this association was limited to localized cancers and was attenuated by adjustment for PSA testing. Survival analysis among incident prostate cancer cases adjusted for stage and grade at diagnosis showed much lower prostate cancer mortality for men with at least a high school education compared to those with less than a high school education (RR= 0.49, 95 CI=0.32–0.76). Conclusions: This study suggests that higher education is associated with slightly increased incidence of prostate cancer, at least partly due to greater use of PSA screening and a greater detection of localized tumors among more highly educated men. The much lower survival rates from prostate cancer among those with less than a high school education cannot be explained by available data and may reflect disparities in treatment. In 1999, 27 of US males over age 55 and older had less than a high school education.     

Uptake of prostate-specific antigen testing for early prostate cancer detection in Sweden

The aim of our study was to estimate uptake of prostate-specific antigen (PSA) testing in an entire country, including time trends and geographical differences. Data from the Swedish Cancer Register on prostate cancer incidence between 1980 and 2007 and published data from the Gothenburg branch of the European randomized study of screening for prostate cancer (ERSPC), a population-based PSA screening study, were used in two models of changes in incidence of prostate cancer as a proxy for uptake of PSA testing in all 24 Swedish counties. The estimated annual PSA testing, irrespective of previous years' exposure, reached a peak of 12% of all men in 2004 and decreased thereafter to 6% in 2007 and varied from less than 5 to 20% between counties. Under the assumption that men who underwent annual PSA testing were previously unexposed to PSA testing, the cumulated uptake of PSA testing in men aged 55-69 years in Sweden increased from zero in 1997 to 56% in 2007. Our study shows that it is possible to estimate uptake of PSA testing in the population from the prostate cancer incidence pattern. There were large geographical variations in uptake of PSA testing despite a uniform health care system in Sweden and there was a substantial increase in the uptake of PSA testing during the study period, despite that there were no national recommendations for PSA-based prostate cancer screening.