Trends in Prostate Specific Antigen (PSA) testing and prostate cancer incidence and mortality in Australia: A critical analysis
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- Title: Trends in Prostate Specific Antigen (PSA) testing and prostate cancer incidence and mortality in Australia: A critical analysis☆
- Author: Thanya Pathirana a,b,*, Rehan Sequeira c, Chris Del Mar b, James A. Dickinson d,Bruce K. Armstrong e, Katy J.L. Bell e
, Paul Glasziou b - Publication: Cancer Epidemiology
- Publisher: Elsevier Inc
- Year: 2022
- Language: English
- Pages: 6
- Format: PDF
- File size: 1,697 KB
- DOI: 0.1016/j.canep.2021.102093
- CBID: CBR265
Abstract
Background
Population trends in PSA testing and prostate cancer incidence do not perfectly correspond. We aimed to better understand relationships between trends in PSA testing, prostate cancer incidence and mortality in Australia and factors that influence them.
Methods
We calculated and described standardised time trends in PSA tests, prostate biopsies, treatment of benign prostatic hypertrophy (BPH) and prostate cancer incidence and mortality in Australia in men aged 45–74, 75–84, and 85 + years.
Results
PSA testing increased from its introduction in 1989 to a peak in 2008 before declining in men aged 45–84 years. Prostate biopsies and cancer incidence fell from 1995 to 2000 in parallel with decrease in trans-urethral resections of the prostate (TURP) and, latterly, changes in pharmaceutical management of BPH. After 2000, changes in biopsies and incidence paralleled changes in PSA screening in men 45–84 years, while in men ≥85 years biopsy rates stabilised, and incidence fell. Prostate cancer mortality in men aged 45–74 years remained low throughout. Mortality in men 75–84 years gradually increased until mid 1990s, then gradually decreased. Mortality in men ≥ 85 years increased until mid 1990s, then stabilised.
Conclusion
Age specific prostate cancer incidence largely mirrors PSA testing rates. Most deviation from this pattern may be explained by less use of TURP in management of BPH and consequent less incidental cancer detection in TURP tissue specimens. Mortality from prostate cancer initially rose and then fell below what it was when PSA testing began. Its initial rise and fall may be explained by a possible initial tendency to over-attribute deaths of uncertain cause in older men with a diagnosis of prostate cancer to prostate cancer. Decreases in mortality rates were many fold smaller than the increases in incidence, suggesting substantial overdiagnosis of prostate cancer after introduction of PSA testing.
Highlights
- • Most deviation in prostate cancer incidence from PSA screening rates may be explained by less use of TURP in BPH management.
- • The initial rise and subsequent fall in prostate cancer mortality may be explained by a possible initial tendency to over-attribute deaths of uncertain cause in older men with a diagnosis of prostate cancer to prostate cancer.
- • The large increases in prostate cancer incidence but minimal changes in its mortality suggest a high degree of overdiagnosis.
1
Introduction
PSA tests were first listed in the Medicare Benefits Schedule (indicating government subsidy of tests requested in the community) in 1989. Following this, age-standardised prostate cancer incidence more than doubled, from 80 per 100,000 in 1982 195 per 100,000 in 2009. This rise in incidence probably reflects increased testing of asymptomatic men with PSA (opportunistic PSA screening), which is a more acceptable and more sensitive screening test than digital rectal examination (the main screening test prior to 1989) , but may lead to greater prostate cancer overdiagnosis. Advocates for screening suggest this is an acceptable price to pay for reducing mortality.
A comparison of temporal trends in PSA testing and prostate cancer incidence does not show a perfect correspondence between the two. Prostate cancer incidence rose before the introduction of PSA testing, and later declined, even while PSA testing was increasing. To explain these differences, we have taken a broader view and explored other changes in urological practice during the same period. The number of core biopsies taken to investigate an elevated PSA increased from 6 cores in the 1990 s to 24 in contemporary practice, thus increasing the chance of a biopsy finding cancer. Prostate cancer incidence may also have been increased by its incidental detection in tissue from transurethral resection of prostate (TURP), which is offered to men with symptoms of urinary obstruction usually associated with benign prostatic hyperplasia (BPH). The later adoption of treatment of BPH symptoms with alpha-blockers such as prazosin and tamsulosin, and 5-alpha reductase inhibitors such as dutasteride, as an alternative to TURP in the 1990 s could have led to an apparent reduction in cancer incidence. Such a trend, however, might have been offset somewhat by an increase in PSA testing, which is usually recommended for men taking these drugs. .
The aim of this paper is to fully describe the changes in PSA testing, prostate biopsy, TURP and prescribing of alpha blockers and 5 alpha-reductase inhibitors to better understand the factors that have contributed to observed changes in prostate cancer incidence and mortality in Australia since the 1980s
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