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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


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


–2012 with a change of even –


11.2% for

PCa incidence between 2010 to 2012


. From 2010 to

2012 the average annual percent change for PCa incidence

was –11.2%

[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



. 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

[4,5] .

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)

[6] .

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

[1] ,

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



. Food habits have also improved by trend

in the industrial nations with a reduced absorption of


[8–10] ,

in which a considerable dependence on

socio-economic, educational, and family status needs to be

considered in this regard

[11] .

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

E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) e 1 4 5 – e 1 4 6

ava ilable at

journal homepage:

DOI of original article:




2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.