Although early detection of prostate cancer (PCa) prior to metastasis significantly reduces mortality, the failure of PSA screening to improve mortality led to concerns that PCa was being over-screened and overtreated.1 However, the reasoning underpinning the USPSTF’s 2012 downgrade has been controversial, particularly with regard to crossover contamination and underrepresentation of Black men in the cited research.2
To examine the influence of the 2012 downgrade on metastatic PCa incidence, we used data from the National Cancer Database, which captures 70% of all new cancers in the US each year.3 From 2004 to 2017, we identified 1,275,410 PCa cases, where 88,987 (7%) were metastatic at initial presentation. Of these, we found that 7% of non-Hispanic (NH) White men, 9% of NH Black men, and 10% of Hispanic men presented with metastatic PCa. We found that 19% of uninsured, 16% of Medicaid insured, and 4% of privately insured patients diagnosed with PCa were metastatic at presentation. Educational status and median household income were derived from the U.S. Census Bureau’s zip code level data, such as patient location, but not patient-level income or education?, which was captured by the NCDB.
We found that the prevalence of metastatic PCa at presentation was stable from 2004 to 2011 but, beginning in 2012, the prevalence began to increase in a trend that continues through 2017, the end of the study period. The increasing trend post-grade “D” recommendation was consistent across all race/ethnicity categorizations, with a statistical significance of p < 0.0001. Among non-Hispanic Black men, those earning less than $30,000/year had 22% greater odds (OR 1.22, 95% CI, 1.14-1.30) of metastatic PCa at diagnosis compared to those earning more than $46,000/year. Compared to non-Hispanic Black men, other racial/ethnic classifications did not show as strong a relationship between median household income and metastatic PCa at presentation, see Figure 1.
Uninsured, non-Hispanic Whites had twice the odds of presenting with metastatic PCa versus those with Medicaid insurance (OR 2.02; 95% CI 1.93-2.12). However, the magnitude of difference between the uninsured and those with Medicaid was not as large among Hispanic (OR 1.43, 95% CI 129-1.59) or non-Hispanic Black (OR 1.15, 95% CI 1.07- 1.23) patients, see Figure 2.
We theorize that the increasing rates of metastatic PCa are due to rapid physician acceptance of the 2012 USPSTF downgrade, as multiple studies demonstrated that from 2011 to 2013 there was a 5-10% drop in PSA tests.4,5 We found that insured patients had decreased odds of presenting with metastatic PCa compared to uninsured patients, with private insurance having the largest effect. Interestingly, the magnitude of protection insurance provided was the largest of all the variables we studied. Higher yearly income was protective against metastatic PCa, but, interestingly, only for non-Hispanic men. Additionally, living in an area with higher rates of high school diploma achievement significantly decreased the risk of metastatic PCa for all racial/ethnic groups studied.
Taken together, there are significant racial and ethnic disparities in the incidence of metastatic PCa diagnosis, partially explained by insurance, income, and educational attainment. To ensure social justice for historically underserved communities, the USPSTF should consider these disparities when reviewing future PSA screening guidelines.
Written by:
- Alan G. Perry, Department of Urology, Mayo Clinic, Jacksonville, FL
- Ram A. Pathak, MD, Department of Urology, Mayo Clinic, Jacksonville, FL
- Tsodikov A, Gulati R, Heijnsdijk EAM, Pinsky PF, Moss SM, Qiu S, et al. Reconciling the Effects of Screening on Prostate Cancer Mortality in the ERSPC and PLCO Trials. Ann Intern Med. 2017; 167: 449–455.
- lic D, Djulbegovic M, Jung JH, et al. Prostate cancer screening with prostate-specific antigen (PSA) test: a systematic review and meta-analysis. BMJ. 2018;362:k3519.
- Bilimoria KY, Stewart AK, Winchester DP, Ko CY. The National Cancer Data Base: A Powerful Initiative to Improve Cancer Care in the United States. Ann Surg Oncol. 2008; 15: 683–690.
- Jemal A, Fedewa SA, Ma J, et al. Prostate Cancer Incidence and PSA Testing Patterns in Relation to USPSTF Screening Recommendations. JAMA 2015;314:2054-61.
- Percy-Laurry A, Altekruse SF, Hossain MB, et al. Association Between Socioeconomic Status and Tumor Grade Among Black Men with Prostate Cancer. J Natl Med Assoc 2018;110:53-7