EURURO Vol. 71 No. 5

E145 844

Letter to the Editor
Re: Scott P. Kelly, Philip S. Rosenberg, William F.
Anderson, et al. Trends in the Incidence of Fatal Prostate
Cancer in the United States by Race. Eur Urol
2017;71:195–201
In their analysis of nine cancer registries of the Surveillance,
Epidemiology, and End-results database referring to the
time period 1975 to 2002, Kelly et al highlight several
important aspects of prostate cancer (PCa) incidence trends
in the USA: (1) in comparison to the early 1990s, an obvious
decline in the detection of fatal PCa by more than 50% has
been observed in the time period 2000–2002, (2) contrari-
wise, the incidence of fatal PCa in men 55 yr has remained
unchanged, and (3) significant differences in incidence rates
between races are obvious with African American men
being affected by fatal PCa more than double as often as
Caucasian men, with an even bigger gap in the age group
55 yr.
Generally, PCa incidence patterns mirror behavioral
trends associated with cancer development risk, changes in
cancer prevention and cancer control strategies, improve-
ments in medical care, and pharmaceutical developments.
The spike in the incidence rate of fatal PCa in the early 1990s
is to be predominantly ascribed to the widespread use of
prostate-specific antigen (PSA) testing. Analog to the
statement of Sophokles in 429 BC (‘‘You will only detect
what you are looking for; what you ignore, will escape’’;
Oedipus the King) and despite the known problem of
length-time bias in screening measures, subsequently also a
numerousness of nonfatal PCa have been detected and
treated; for a fraction of these patients no curative
treatment option would have been available if they had
been diagnosed later. Recently a reduction in PCa-related
incidence and the accordant mortality rates have been
recognized: in the USA. The average annual percent change
was –6.6% for the incidence and –3.6% for mortality in the
time period 2008[2_TD$DIFF]–2012 with a change of even – [3_TD$DIFF]11.2% for
PCa incidence between 2010 to 2012 . From 2010 to
2012 the average annual percent change for PCa incidence
was –11.2% Also, for Germany the Robert Koch Institute
reported a comparable reduction of the PCa incidence by
4.4% from 2011 to 2012 alongside a reduced cancer-specific
mortality . Having said that, there are current reports also
indicating—besides the favored decrease in the incidence of
indolent tumors—an increased fraction of advanced PCa,
most probably as a result of reduced use of PSA screening
subsequent to the downgraded recommendation by the US
Preventive Services Task Force One loophole out of the
dilemma of overdiagnosis of indolent PCa on the one hand
and late detection of clinically relevant tumors on the other
hand could be the application of optimized risk adapted
screening programs (eg, including the criteria of the
PROBASE trials) By initiating the first round of PROBASE
criteria-based screening at the age of 45–50 yr, fatal PCa in
men 55 yr, the incidence of which is stable and not
declining based on the results by Kelly et al would be
detected in due time . Furthermore, such—in the future
evidence-based—screening programs must be implemen-
ted covering men of any race, in which collaboration with
and support of national and international patient advocacy
groups might be beneficial.
Finally, it should be considered that physicians tend to
overestimate the actual impact of medical care improve-
ments including diagnostic and therapeutic measures and
pharmaceutical developments. However, the impact of
environmental and behavioral parameters as well as
preventive measures seems to be underestimated. Behav-
ioral factors (environment, alimentation, medical mainte-
nance) especially most likely play an important role in PCa
development . Food habits have also improved by trend
in the industrial nations with a reduced absorption of
carcinogens in which a considerable dependence on
socio-economic, educational, and family status needs to be
considered in this regard Furthermore, especially in
the male population relevant for PCa diagnosis (ie, men
aged 50–70 yr) increasingly statins and acetylsalicylic acid
are taken for the reduction of cardiovascular risk, which are
considered preventive for PCa development .
In summary, we have observed a reduction in PCa
incidence and PCa-related mortality, what undeniably
should be valued as a positive trend. However, subsequent
to changing recommendations related to PSA screening
measures, variations in the distribution of primary tumor
stages are already observed in the USA and can be also
expected in European countries. Analyses such as provided
by Kelly et al are extremely important, as they support
urologists and oncologists in their assessment of diagnostic
ava ilable at
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0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.