Despite progress, too many are dying of prostate cancer

After years of declines, more men have been diagnosed with prostate cancer in recent years.

The incidence of prostate cancer had dropped for several years, but the number of new cases has risen 3% annually since 2014, according to the American Cancer Society. The number of men being diagnosed with advanced stage prostate cancer has risen 5% annually in recent years.

William Dahut, MD, chief scientific officer for the American Cancer Society, said it’s especially disturbing to see the uptick in people with more advanced stages of the disease.

“We are definitely seeing an increase in men being diagnosed with prostate cancer. But what's really concerning is that it's being driven by men being diagnosed with more advanced disease,” Dahut says.

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In an interview with Chief Healthcare Executive®, Dahut talks about some of the troubling trends in prostate cancer. He also talks about the need for doctors, and health systems, to be having more discussions with their patients about the disease. And he says there needs to be better education about some misconceptions about screenings for prostate cancer.

While the cancer society promotes the importance of shared decision making with prostate cancer, Dahut says he is concerned that fewer people are being screened, which could be contributing to the higher rates of men with more advanced prostate cancer.

More than 35,000 men are expected to die of prostate cancer in 2024, according to projections from the American Cancer Society. “That's not a small number,” Dahut says.

Prostate cancer deaths dropped by half from 1993 to 2013, but the rate has stabilized in recent years. Dahut says that could be tied to more people being diagnosed with later stages of prostate cancer.

“There are many men whose prostate cancer will never cause them harm, and I think we need to be thoughtful about how we intervene,” he says. “But again, you know, way too many people are still dying of prostate cancer.”

With September being Prostate Cancer Awareness Month, Dahut says he hopes to see a greater recognition of the need for more discussion, education and screenings. (See part of our conversation with Dr. Dahut in this video. The story continues below.)

Screenings

Screening for prostate cancer has become a somewhat thorny issue in recent years.

The U.S. Preventive Services Task Force said in 2018 that periodic screening for men between 55 and 69, via a blood test, should be an individual decision.

“Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men,” the task force said. “However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction.”

The task force also said in its 2018 guidelines that it doesn’t recommend any screenings for men 70 and older. The task force is in the midst of revising its recommendations.

Today, Dahut says there should be more discussions with patients, and a better understanding among clinicians as well.

“I think our primary care doctors were told that this test was harmful,” Dahut says. “And, you know, that's tough to get that out of one's pattern of work.”

Dahut would like to see more doctors and health systems having conversations with patients, especially those at higher risk, such as a family history.

He also notes that discussions, and screenings, don’t have to lead to surgery.

“At any point along the way, one can sort of stop the process if one decides they don't want to go on,” he says. “So I think there was this concern that once somebody had a PSA test, they were on a sort of a one-way track that the next thing you know, they have their prostate out, and they're impotent and incontinent two weeks later.”

But he stresses that screening doesn’t have to go straight to surgery even with a positive diagnosis.

“One can have thoughtful decisions along the way, including active surveillance, which people can be followed very closely with early stage prostate cancer that appears indolent, and either defer treatment or delay treatment or may never need treatment,” he says.

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Addressing misconceptions

More people would be willing to be screened if they didn’t have misconceptions about what’s involved, Dahut suggests.

Too many aren’t aware that the first step is a blood test, according to an American Cancer Society survey. Three in five men (60%) incorrectly think that the first screening for prostate cancer is a digital rectal exam.

About half (49%) said they would be more likely to have a conversation with a clinician if they knew the initial screening was a simple blood test, according to the survey. The initial screening typically involves testing prostate-specific antigen (PSA) levels in the blood.

More men should be made aware that erectile dysfunction can be an indication of prostate cancer. The survey found 56% of men weren’t aware of that link.

Most men with erectile dysfunction don’t have prostate cancer, Dahut notes. But seeing a urologist is still a good step, and Dahut says patients would likely get a blood test for prostate cancer.

Men who have a family history of prostate cancer should undergo screenings, since they are at higher risk.

“Prostate cancer is probably the disease that has one of the strongest links to family history,” Dahut says. “It actually has a fairly high genetic component.”

Patients also have better treatment options than they did 20 to 30 years ago, he says.

Most surgeries for prostate cancer are now done robotically, and the advent of robotic surgery has “been a great equalizer,” Dahut says.

“I think that's brought an increase in the ability for good care to be done in many places,” he says.

Patients also have more viable options beyond surgery, including radiation therapy, which has also improved over time.

“I think there's a lot of fear about the fact that the therapies can lead to incontinence, potentially, or impotence,” he says. “You know, the therapies are better than they have been.”

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Steps for doctors and health systems

More patients should be having conversations with physicians about screening for prostate cancer, Dahut says.

Too many people, including clinicians, have been under the impression that screenings for prostate cancer are more harmful than beneficial. And that’s had an impact on the number of men being tested, Dahut suggests.

“Our concern is that many people were simply told not to do it, and I think that overall is harmful,” he says.

While he advocates for shared decision-making with patients and respecting those who say they don’t want to be tested, Dahut says doctors could be offering more and better information.

Some health systems have required doctors to have conversations about screenings for prostate cancers, including a requirement to include the conversation in electronic health records. Dahut pointed to Duke University and Washington University in St. Louis as organizations that have taken that step, leading to “dramatic increases” in screening.

“Having that as a requirement of the health records to at least have those discussions, I think actually would greatly increase the number of people who are being screened,” he says.

Many men may choose not to be screened, or to simply be monitored even if they are found at higher risk. But he thinks more screening would lead to more people being diagnosed at earlier stages.

Dahut says greater awareness of screenings, dispelling myths, and more conversations with patients could make a difference.

“When those discussions occur, I think that has an ability to really improve outcomes,” he says.