Association of the USPSTF Grade D Recommendation Against Prostate-Specific Antigen Screening With Prostate Cancer-Specific Mortality

Abstract

Importance: The 2012 US Preventive Services Task Force (USPSTF) Grade D recommendation against prostate-specific antigen (PSA) screening for all men has been controversial, with data documenting a shift to a higher stage of disease at diagnosis. The association between the Grade D recommendation and prostate cancer-specific mortality (PCSM) among contemporary cohorts, however, is unclear.

Objective: To evaluate PCSM rates between 1999 and 2019, comparing trends in rates before and after the change in the 2012 USPSTF screening guideline to assess its association with PCSM.

Exposure: The 2012 USPSTF Grade D recommendation against PSA screening for all men.

Design, setting, and participants: This cross-sectional study used Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research maintained by the National Center for Health Statistics to collect data on cause of death for all individuals who died of prostate cancer in the US from 1999 to 2019. Analysis was performed from January to August 2021.

Main outcomes and measures: Trends in PCSM rates were calculated from 1999 to 2012 and from 2014 to 2019, with a washout year of 2013, using linear regression, with year and binary indicator of pre-2013 and post-2013 status as interaction terms. Trends were further analyzed by age, race and ethnicity, urbanization category, and US Census region. Other measures included diagnosis of localized or metastatic prostate cancer and overall cancer mortality.

Results: A total of 618 095 patients died of prostate cancer in the US from 1999 to 2019. Age-adjusted PCSM decreased linearly at a rate of -0.273 per 100 000 population per year from 1999 to 2012 and stalled at a rate of -0.009 per 100 000 per year from 2014 to 2019 (P < .001). This finding was significant among men aged 60 years or older, especially among men aged 60 to 69 years, men aged 80 years or older, and among Black men. Men aged 60 to 64 years had a decreasing, age-adjusted PCSM rate of -0.0088 per 100 000 population per year prior to 2013 followed by an increasing rate of 0.0014 per 100 000 per year. Men aged 65 to 69 years had a decreasing, age-adjusted PCSM rate of -0.024 per 100 000 population per year prior to 2013 followed by an increasing rate of 0.0011 per 100 000 population per year. Men aged 80 years or older had the largest absolute difference between rates before and after 2013 compared with all other age groups, with a difference of 0.06 for men aged 80 to 84 years and 0.07 for men 85 aged years or older. Black men had a decreasing, age-adjusted PCSM rate of -0.700 per 100 000 population per year prior to 2013 followed by a flattened rate of -0.091 per 100 000 population per year. Changes were observed across races and ethnicities, urbanization categories, and US Census regions and were accompanied by increased diagnoses of metastatic disease, which are inconsistent with mortality trends across all malignant neoplasms.

Conclusions and relevance: This cross-sectional study using comprehensive PCSM data through 2019 demonstrated decreasing PCSM rates that flattened or increased after the 2012 USPSTF Grade D recommendation, suggesting that decreased PSA screening may be a factor associated with this change. This change was seen across ages, races and ethnicities, urbanization categories, and US Census regions. The updated 2018 USPSTF guideline supporting shared decision-making may reverse these trends in the coming years.

Figure 1.. Age-Adjusted Rates of Prostate Cancer–Specific Mortality (PCSM) per 100 000 Population by 5-Year Age Group

There was significant (P < .001) change in the rate of age-adjusted PCSM after 2013 for men aged 60 years or older. Rates of change were calculated using linear regression, with the interaction term of year and binary indicator of pre-2013 and post-2013 status.

Figure 2.. Age-Adjusted Rates of Prostate Cancer–Specific Mortality (PCSM) per 100 000 Population by 5-Year Age Group by Race and Ethnicity

A, Among Black men, there was a significant flattening or an increase (P < .05) in the age-adjusted rate of PCSM after 2013 for almost all age groups; 50 to 54 years and 85 years or older were the only exceptions. B, White men aged 60 years or older experienced significant (P < .001) flattening in the age-adjusted rate of PCSM after 2013, although to a lesser degree compared with Black men. C, Among Hispanic men, there was no significant change observed in age-adjusted PCSM rates before and after 2013. D, Among non-Hispanic men, those aged 60 years or older experienced significant (P < .001) flattening in the age-adjusted rate of PCSM after 2012.

Figure 3.. Age-Adjusted Rates of Localized and Metastatic Prostate Cancer Diagnoses Over Time

A, Age-adjusted rate of diagnosis of localized prostate cancer per 100 000 population showed a relative increase (P ≤ .04) among men aged 70 to 85 years or older. B, Age-adjusted rate of diagnosis of metastatic prostate cancer per 100 000 population significantly (P ≤ .03) increased after 2013 among all age groups.

Figure 4.. Age-Adjusted Rates of Overall Cancer Mortality per 100 000 Population

A, For men, overall cancer mortality decreased steadily from 1999 to 2019. Within many age groups, including men aged 50 to 59 years, the rate of age-adjusted cancer mortality significantly decreased between 1999 to 2012 and 2014 to 2019, the opposite trend to prostate cancer–specific mortality. B, For men and women, overall cancer mortality similarly decreased from 1999 to 2019. Age-adjusted overall cancer mortality decreased significantly between 1999 to 2012 and 2014 to 2019 for all age groups with the exception of individuals aged 60 to 69 years, for whom the rate subsequently flattened after 2013.