Variation in Prostate-Specific Antigen Testing Rates and Prostate Cancer Treatments and Outcomes in a National 20-Year Cohort

Abstract

IMPORTANCEThe diagnostic activity for prostate cancer has increased during the past decades.However, the benefit and harm of the increased diagnostic activity have not been quantified in detail for a country or a large region.OBJECTIVE The aim of this study was to evaluate and quantify the association between increases in diagnostic activity driven by prostate-specific antigen testing and incidence of prostate cancer diagnosis, treatment, and mortality. DESIGN, SETTING, AND PARTICIPANTSThis cohort study used the Proxy-Based Risk-Stratified Incidence Simulation Model-Prostate Cancer to examine observed data on all Swedish men with prevalent prostate cancer and compare them with a corresponding, hypothetical, simulated scenario with more restrictive diagnostic activity. All men aged 40 to 100 years living in Sweden during the time period 1996 to 2016 with incident and prevalent prostate cancer were included. The second scenario is the corresponding, hypothetical, simulated scenario where diagnostic activity remained constant as of 1996 (the beginning of the prostate-specific antigen testing era) throughout the study period. EXPOSURES High or low diagnostic activity for prostate cancer. MAIN OUTCOMES AND MEASURES Incidence of prostate cancer diagnosis, treatment (deferred treatment, curative treatment, and hormonal treatment), and prostate cancer mortality.RESULTS During the study period from 1996 to 2016, 188 884 men were diagnosed with prostate cancer at a median (interquartile range) age of 71 (64-77) years. Compared with the low-diagnostic activity scenario, in the high-diagnostic activity scenario, the number of men diagnosed with prostate cancer was 48% higher (423 vs 286 [95% CI, per 100 000 men per year), 148% more men were diagnosed with low-or intermediate-risk cancer (221 vs 89 [95% CI, 73-105] per 100 000 men per year), and 108% more men received curative treatment per 100 000 men per year). There were up to 15% fewer prostate cancer deaths in the scenario with high-diagnostic activity (incidence rate ratio, 0.85; 95% CI, 0.82-0.88).CONCLUSIONS AND RELEVANCE This study's results suggest that increased prostate-specific antigen testing and diagnostic activity are associated with a larger number of men being diagnosed with prostate cancer, predominately with low-and intermediate-risk disease. The increased diagnostic activity was associated with a 2-fold increase in curative treatment and a modest decrease in mortality.

Diagnostic activity impacts lifetime risk of prostate cancer diagnosis more strongly than life expectancy

“…We applied PRISM-PC to estimate the lifetime risk of a prostate cancer diagnosis under three different levels of diagnostic activity and life expectancy. Our PRISM-PC model has been described in detail previously [ 8 , 11 ]. For a hypothetical birth cohort, the model simulates life trajectories from age 40 to age 100 for each man in the cohort.…”

Current prostate cancer screening and treatment strategies may not support a holistic nationwide program

“…16 However, the impact of treating screen-detected low-grade tumors on the overall quality of life for men has been a point of contention in recent studies. 17,18 A diagnosis of prostate cancer also raises significant psychological distress, with several studies reporting minimum to severe anxiety associated with the PSA test. 19 Nevertheless, a follow-up test to confirm the diagnosis of prostate cancer further creates a cycle of anxiety and depression that affects the individual's day-to-day life.…”

“…The correlation between elevated serum PSA levels and the possibility of finding a tumor with prostate biopsy has marked the modern age of prostate cancer diagnosis, which, unfortunately, has come with consequences such as incontinence and sexual dysfunction 16 . However, the impact of treating screen‐detected low‐grade tumors on the overall quality of life for men has been a point of contention in recent studies 17,18 . A diagnosis of prostate cancer also raises significant psychological distress, with several studies reporting minimum to severe anxiety associated with the PSA test 19 .…”

The relationship between serum albumin and prostate-specific antigen: A analysis of the National Health and Nutrition Examination Survey, 2003–2010

“…For the first time in 1980, Papsidero et al quantified PSA levels in human blood, signaling the clinical application of PSA, which has since become a common screening tool for PCa today ( 8 – 10 ). Bergengren et al revealed that using PSA testing resulted in a 15% decrease in prostate cancer deaths from 1996 to 2016 ( 11 ) and it is crucial to clarify the factors that affect PSA in order to ensure quality screening and prevent missed diagnoses. According to recent studies, a higher level of folate may reduce PSA levels and sugar consumption is positively and independently linked to PSA levels in adult American males without prostate cancer ( 12 , 13 ).…”