Prostate Cancer Incidence and Survival, by Stage and Race/Ethnicity — United States, 2001–2017
Weekly / October 16, 2020 / 69(41);1473–1480
David A. Siegel, MD1; Mary Elizabeth O’Neil, MPH1; Thomas B. Richards, MD1; Nicole F. Dowling, PhD1; Hannah K. Weir, PhD1 (View author affiliations)View suggested citation
What is already known about this topic?
Among U.S. men, prostate cancer is the second leading cause of cancer-related death. The incidence of distant stage prostate cancer (signifying spread to parts of the body remote from the primary tumor) has increased since 2010.
What is added by this report?
Additional years of data show continued increases in the incidence of distant stage prostate cancer in the United States. The percentage of distant stage prostate cancer increased from 4% in 2003 to 8% in 2017. Five-year survival for distant stage prostate cancer improved from 28.7% during 2001–2005 to 32.3% during 2011–2016; for the period 2001–2016, 5-year survival was highest among Asian/Pacific Islanders (42.0%), followed by Hispanics (37.2%), American Indian/Alaska Natives (32.2%), Black men (31.6%), and White men (29.1%).
What are the implications for public health?
Understanding the disease trends of distant stage prostate cancer and disparities in prostate cancer survival by stage, race/ethnicity, and age can guide public health planning related to screening, treatment, and survivor care.
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Among U.S. men, prostate cancer is the second leading cause of cancer-related death (1). Past studies documented decreasing incidence of prostate cancer overall since 2000 but increasing incidence of distant stage prostate cancer (i.e., signifying spread to parts of the body remote from the primary tumor) starting in 2010 (2,3). Past studies described disparities in prostate cancer survival by stage, age, and race/ethnicity using data covering ≤80% of the U.S. population (4,5). To provide recent data on incidence and survival of prostate cancer in the United States, CDC analyzed data from population-based cancer registries that contribute to U.S. Cancer Statistics (USCS).* Among 3.1 million new cases of prostate cancer recorded during 2003–2017, localized, regional, distant, and unknown stage prostate cancer accounted for 77%, 11%, 5%, and 7% of cases, respectively, but the incidence of distant stage prostate cancer significantly increased during 2010–2017. During 2001–2016, 10-year relative survival for localized stage prostate cancer was 100%. Overall, 5-year survival for distant stage prostate cancer improved from 28.7% during 2001–2005 to 32.3% during 2011–2016; for the period 2001–2016, 5-year survival was highest among Asian/Pacific Islanders (API) (42.0%), followed by Hispanics (37.2%), American Indian/Alaska Natives (AI/AN) (32.2%), Black men (31.6%), and White men (29.1%). Understanding incidence and survival differences by stage, race/ethnicity, and age can guide public health planning related to screening, treatment, and survivor care. Future research into differences by stage, race/ethnicity, and age could inform interventions aimed at improving disparities in outcomes.
Cases included males with malignant† prostate cancer§ and excluded cases diagnosed by autopsy and death certificate only. Incidence data were from USCS during the period 2003–2017 and covered 100% of the U.S. population. Age-adjusted rates were expressed per 100,000 men.¶ Trends in incidence were described using annual percent change (APC) and average annual percent change (AAPC) calculated by joinpoint regression. Statistically significant APC and AAPC were different from zero (p<0.05).** Survival data were from CDC’s National Program of Cancer Registries (NPCR)–funded registries that conducted active case follow-up or linkage with CDC’s National Death Index, and covered 94% of the U.S. population.†† Survival analysis included cases diagnosed during 2001–2016 with follow-up through December 31, 2016. Relative survival (cancer survival in the absence of other causes of death) was calculated§§ for 1, 5, and 10 years after diagnosis, using expected life tables stratified by age, sex, race/ethnicity, socioeconomic status, geographic location, and calendar year of diagnosis.¶¶ Differences between relative survival estimates were determined by comparing 95% confidence intervals (CIs), which allowed for an informal, conservative comparison of estimates. Differences in relative survival were noted when CIs did not overlap.
Incidence and survival were stratified by stage, age, year of diagnosis, and race/ethnicity. There were four categories for race (Black, White, AI/AN, and API) and one for ethnicity (Hispanic). Men categorized by race were all non-Hispanic. Men categorized as Hispanic might be of any race. Stage was defined using Summary Stage, the staging system used by the cancer surveillance community and defined with the following categories: localized (tumor is confined to the organ of origin without extension beyond the primary organ), regional (direct extension of the tumor to adjacent organs or structures or spread to regional lymph nodes), distant (cancer has spread to parts of the body remote from the primary tumor), and unknown.***
During 2003–2017, a total of 3,087,800 new cases of prostate cancer were diagnosed in the United States (Table 1). Over this 15-year period, age-adjusted incidence decreased from 155 per 100,000 in 2003 to 105 in 2017 (Supplementary Table 1, https://stacks.cdc.gov/view/cdc/94592). During 2003–2017, incidence was highest for men aged 70–74 years (764) and Black men (202). Localized, regional, distant, and unknown stage prostate cancer accounted for 77%, 11%, 5%, and 7% of total cases, respectively. The percentage of localized cases decreased from 78% in 2003 to 70% in 2017, and distant cases increased from 4% in 2003 to 8% in 2017. White men had lower percentages of distant (5%) and unknown stage (6%) prostate cancer than did any other race/ethnicity. The overall incidence of prostate cancer decreased during 2003–2017 (AAPC = −2.5%) but increased for cases diagnosed at distant stage (AAPC = 2.2%). More specifically, the increase was observed during 2010–2017 (APC = 5.1%) and began in 2011 or earlier, regardless of race/ethnicity.
During 2001–2016, among 3,104,380 men with survival data, 5-year and 10-year relative survival was 97.6% and 97.2%, respectively (Table 2). Men aged ≤49 years and ≥80 years had the lowest 10-year relative survival (95.6% and 82.7%, respectively). For localized prostate cancer, 10-year relative survival was 100%. Ten-year relative survival for regional, distant, and unknown stage was 96.1%, 18.5%, and 78.1%, respectively. For distant stage prostate cancer, 10-year relative survival was highest for ages 60–64 years (21.8%) and was <20% for ages <55 and ≥70 years.
Comparing 2001–2005 with 2011–2016, 5-year relative survival improved from 97.5% to 99.3% for regional stage and from 28.7% to 32.3% for distant stage prostate cancer (Table 3). During 2001–2016, 5-year survival for distant stage prostate cancer was highest among API (42.0%), followed by Hispanics (37.2%), AI/AN (32.2%), Black men (31.6%), and White men (29.1%). Survival by race/ethnicity showed differences by age (Supplementary Table 2, https://stacks.cdc.gov/view/cdc/94593). For unknown stage prostate cancer, 5-year survival was higher for Hispanic (84.4%) and White men (82.8%) than Black men (79.1%).
Although approximately three fourths of U.S. men with prostate cancer have localized stage at diagnosis, an increasing number and percentage of men have received diagnoses of distant stage prostate cancer. Survival with distant stage prostate cancer has improved, but fewer than one third of men survive 5 years after diagnosis. Survival disparities by age and race/ethnicity were noted for distant stage prostate cancer during all three periods (i.e., 2001–2005, 2006–2010, and 2011–2016) studied.
The U.S. Preventive Services Task Force (USPSTF) has issued several recommendations that discuss the possible benefits and harms of screening for prostate cancer using prostate-specific antigen (PSA).††† In 2012, USPSTF concluded that the benefits of PSA-based screening do not outweigh the harms and recommended against PSA-based screening for prostate cancer for men of all ages. This recommendation likely contributed to a decrease in overall reported prostate cancer incidence and might have contributed to an increase in the percentage and incidence of distant stage prostate cancer (2,3). Despite decreasing incidence of localized stage prostate cancer, 130,658 to 190,570 new cases were diagnosed each year in the United States during 2003–2017. Even though 10-year survival for localized stage prostate cancer is 100%, many of these patients need treatment, including surgery or radiation, often face long-term effects of their treatment (e.g., urinary incontinence and erectile dysfunction), and ≤6% progress to metastatic prostate cancer (6). Improvements in survival for distant stage prostate cancer might reflect changes in clinical management, which includes increased use of new agents and treatment innovations, such as new hormone and antibody therapies (6). Despite these improvements in survival, increases in distant stage prostate cancer incidence might have contributed to the plateauing of previously declining prostate cancer mortality during 2013–2017 (1,2).
Five-year survival for all stages combined was higher for White men than Black or Hispanic men. However, survival for distant stage prostate cancer was higher for Black than White men, which is different from a past study reporting higher survival for White men than Black men during 2001–2009, but with overlapping 95% CIs (4). In addition, unknown stage prostate cancer represented a higher percentage of total cases (7%) than distant stage prostate cancer (5%), and survival for unknown stage prostate cancer was higher for Hispanic and White men than Black men. Men in the unknown stage category, who had a 5-year relative survival of 84.3%, might include a mixture of situations, such as men not healthy enough for a staging workup, situations where staging is not needed to guide treatment decisions, lack of access to care, or incomplete recording in the medical record (7). Past data suggest that social inequities by race contribute to worse outcomes for Black men than White men with prostate cancer (8). Survival based on distant stage and race/ethnicity might need to be interpreted in the context of the incidence and survival for other prostate cancer stages, as well as diagnostic procedures and social determinants of health such as access to care (7,8).
Although survival by age varied by stage, survival was lowest for ages >75 years for regional, distant, and unknown stage prostate cancer. Lower survival for distant stage at age >75 years compared with younger ages might be secondary to more rapid development of resistant prostate cancer, reduced ability to receive available therapies, and impact of comorbidities (5). Ten-year survival was lower for men aged ≤49 years compared with all ages except ≥80 years. Prostate cancer incidence in men ≤49 years has risen over the past 3 decades, and lower survival for this age group has been reported (9). Prostate cancer behavior, genetics, family history, and treatment patterns might affect prostate cancer incidence and survival patterns for men aged ≤49 years (9).
The findings in this report are subject to least three limitations. First, prostate cancer cases missing from the dataset could result in an undercount of prostate cancer incidence,§§§ and delays in reporting could undercount incidence over the most recent years of the study (10). Second, Collaborative Cancer Staging coding, which was used from 2003 to 2015 to code stage data, might explain the lower numbers of unknown stage cases during those years.¶¶¶ Finally, confidence intervals could not be generated for all survival results that are rounded to 100.0%, and values listed as 100.0% only mean that no excess deaths were observed.
In 2018, USPSTF issued a new recommendation stating that prostate cancer screening for men aged 55–69 years should be an individualized decision based on personal preferences when weighing the benefits and harms of screening,**** and several professional organizations have similarly recommended shared decision-making for men deciding about prostate cancer screening.†††† Understanding incidence and long-term survival by stage, race/ethnicity, and age could inform messaging related to the possible benefits and harms of prostate cancer screening and could guide public health planning related to treatment and survivor care. Further research is needed to examine how social determinants of health affect prostate cancer diagnosis and treatment; findings should inform interventions to decrease disparities in outcomes.
Reda J. Wilson, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC; state and regional cancer registry and health department personnel.
Corresponding author: David A. Siegel, email@example.com, 770-488-4426.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.
¶ Rates were adjusted to the 2000 U.S. standard population.
** A maximum of two joinpoints were used to determine a change in direction of trend.
†† Registries met USCS publication criteria and included all U.S. states and the District of Columbia except for Connecticut, Hawaii, Indiana, Iowa, Kansas, and New Mexico.
§§ The cohort method was used to estimate survival when all patients had a full 1, 5, and 10 years of follow-up. The complete method was used when not all patients had the full 5 or 10 years of follow-up for 5-year and 10-year survival time estimates. https://surveillance.cancer.gov/survival/cohort.htmlexternal icon.
*** Defined by merged Summary Stage. https://www.cdc.gov/cancer/uscs/public-use/dictionary/merged-summary-stage.htm and https://training.seer.cancer.gov/collaborative/intro/systems_review.htmlexternal icon.
††† Information about the benefits and harms of prostate cancer screening can be found at the CDC website. Digital rectal examination to screen for prostate cancer is not recommended by USPSTF because of lack of evidence of the benefits. https://www.cdc.gov/cancer/prostate/basic_info/benefits-harms.htm, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening-2012external icon, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screeningexternal icon.
†††† https://www.auanet.org/guidelines/prostate-cancer-early-detection-guidelineexternal icon; https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/acs-recommendations.htmlexternal icon; https://www.acpjournals.org/doi/10.7326/0003-4819-158-10-201305210-00633external icon; and https://www.aafp.org/afp/2018/1015/od1.htmlexternal icon.
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Suggested citation for this article: Siegel DA, O’Neil ME, Richards TB, Dowling NF, Weir HK. Prostate Cancer Incidence and Survival, by Stage and Race/Ethnicity — United States, 2001–2017. MMWR Morb Mortal Wkly Rep 2020;69:1473–1480. DOI: http://dx.doi.org/10.15585/mmwr.mm6941a1external icon.
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