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Trends in Prostate Cancer Mortality in the United States of America, by State and Race, from 1999 to 2019: Estimates from the Centers for Disease Control WONDER Database - Beyond the Abstract

In the United States of America (USA), prostate cancer (PC) is the second most common cancer and a leading cause of cancer mortality in males.1 In the 1990s, there was a steep rise in PC incidence attributed to broad use of PSA screening.2 After 2012, when the US Preventive Services Taskforce (USPSTF) recommended against PSA screening in all age groups irrespective of race or family history, the PC incidence decreased.3-5


However, while the overall incidence is decreasing, there is still great variability in mortality rates by race and geography.3,6 In our article "Trends in Prostate Cancer Mortality in the United States of America, by state and race, from 1999 to 2019: estimates from the centers for disease control WONDER database," we present a detailed analysis of the trends in prostate cancer mortality in the US from 1999 to 2019, with a focus on variations by state and race.7

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In our study, we used the CDC WONDER database provided publicly online through the National Center for Health Statistics and Vital Statistics.8,9 The database includes age-standardized mortality rate (ASMR) data collected based on the ICD code for PC (ICD 10 Code 61) and updated annually by the national civil registration systems. We previously conducted similar analyses for other cancer types, including lung cancer, through our collaboration at MDRcollab (https://www.mdrcollab.com).10,11 We extracted ASMR grouped by state, year and race using the CDC WONDER database. A student t-test was used to compare mortality rates between two racial groups (White and Black men). To perform a trend analysis, we utilized the Joinpoint Command Line software, which computes the ASMR annual percentage change based on continuous data points and detects significant trends.12 Furthermore, we analyzed ASMR relative changes before and after 2012, when USPSTF updated their recommendations and did an interrupted time series (ITS) analysis with SAS Marco by Caswell for the states that had significant ASMR increase after the recommendation change; the time-interruption point was chosen as 2017 to analyze the impact of the guideline changes.13-15

The primary analysis revealed several key findings. First, the overall ASMR for PC in the US declined by 52% from 1999 to 2019. This is a significant decrease, reflecting the improvements in screening and therapeutic modalities, especially for advanced disease.6 However, our findings note that the decline was not uniform across all states and racial groups. The ASMR decline was slower in the South and West compared to the Northeast and Midwest. This may be due to differences in access to healthcare and screening programs, as well as differences in risk factors such as smoking and obesity.16-18 We also found significant ASMR disparities by race. Black men (BM) had the highest ASMR in 2019 (13.2%), followed by white (7.3%), American Indian/Alaskan (3.2%) and Asian (3.2%) men. Of note, BM still had the higher ASMR in 2019, despite having the biggest and most rapid decline (-44.6%) in mortality over the study period after Asian men (-44.8%). Some studies suggest that BM have a higher risk of earlier onset and more aggressive PC phenotype, however, it is suspected that social determinants of health may impact these observations.19,20 In addition, data show that BM have lower rates of PSA screening, guideline-based radiation therapy, and bone scans compared to white men (WM), possibly associated with poor access to healthcare and education about screening.21-23 Interestingly, after adjusting for healthcare access and treatment, BM appears to have similar or even better survival rates than WM.24-27 These findings highlight the need for targeted interventions to address those disparities.

In 2012, the USPSTF updated their recommendations to Grade D, discouraging PSA measurement for prostate cancer screening in men of all ages irrespective of ethnicity and family history.28,29 As our study period overlapped with the changes in USPSTF guidelines from 2012, we performed a subgroup analysis comparing ASMR relative change between 1999–2012 and 2012–2019. ASMR decreased from 1999–2012 with a relative change of −30.84, which was reduced to −1.35 from 2012–2019 in WM. A similar pattern was seen in BM, with a relative change of −38.02 from 1999-2012 and −12.67 from 2012–2019. While ASMR decreased for both WM and BM in all states and DC between 1999-2012, it increased in 22 states in WM and 7 in BM after 2012. For the states that had the increase, further ITS analysis showed that for WM, 11/22 (50%) states showed a significant increase post-2017, and 7/22 (31.8%) had a significant increasing trend in ASMR post-2012. For BM, all 7 states showed an increase in ASMR post-2012. These results indicate that ASMR has increased post-2012 changes in USPSTF guidelines in many states, especially for WM. Similar trends are validated by SEER database analysis. As a result of the 2012 USPSTF guideline change, the incidence of metastatic prostate cancer increased, associated with more adverse clinical features and a lower survival rate.29,30 USPSTF recommendation relied on the results of two trials, and the rationale was that PSA screening led to overdiagnosis and overtreatment.31,32However, there is concern that this was based on misinterpreted data due to contamination of the control group and a decrease in the power of the study, leading to negative results.32 Overall, these observations can be associated with two different trends; an increase in ASMR of PC in recent years and decreasing the racial gap with an increase in mortality in WM. Those findings highlight the need to reconsider PSA-based screening, while overtreatment can be managed with other approaches like rising active surveillance.33

We note that the overall decline in prostate cancer mortality rates is encouraging, but efforts are needed to address the persistent disparities by race and geography. With this analysis, we suggest that targeted interventions, such as increasing access to screening programs and improving healthcare quality in underserved areas, could help to reduce these disparities and improve prostate cancer outcomes.

Overall, the article provides a detailed and comprehensive analysis of trends in prostate cancer mortality rates in the US over the past two decades. The findings highlight the successes and challenges of efforts to reduce the burden of prostate cancer. Our study underscores the need for continued efforts to address disparities by race and geography. The article is a valuable contribution to the field of public health, and it should be of interest to healthcare providers, policymakers, and researchers alike.

Written by:

  • Chinmay Jani, MD, Department of Internal Medicine, Mount Auburn Hospital, Cambridge, MA, USA, Harvard Medical School, Boston, MA, US
  • Pavlina Chrysafi, MD, Department of Internal Medicine, Mount Auburn Hospital, Cambridge, MA, USA, Harvard Medical School, Boston, MA, US
  • Rana R McKay, MD, University of California San Diego, San Diego, CA, USA
References:

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