AUA 2017: USPSTF Fallout – Is Disease Burden at Diagnosis of Metastatic Disease Rising?

Boston, MA ( The United States Preventative Services Task Force (USPSTF) grade D recommendation has been met with heavy controversy. Long-term influences of decreased PSA screening rates on prostate cancer specific mortality (PCSM) and metastatic disease rates have not been previously analyzed on a population-based level. Dr. Jared Schober at the Lahey Hospital and Medical Center presents PSA at the time of diagnosis as a rough surrogate of disease burden and predictor of metastatic disease rates.

Utilizing the National Cancer Database (NCDB) from 2004-2014, Dr. Schober and colleagues divided PSA at initial cancer diagnosis as a categorical indicator (0.2-3.9, 4.0-10.0, 10.1-20, and >20 ng/mL) of metastatic disease status (M1). Over the 10-year period, the proportion of metastatic disease at the time of diagnosis increased for every PSA group, with the most significant increase in patients with PSA > 20. Three points of exponential rise are noted: from 8.1-8.5% from 2004 through 2007, to approximately 14% by 2011. After the fully revised USPSTF recommendation in 2012, the proportion sky-rocketed to over 22% in 2014.

As an independent predictor of metastatic disease (p<0.001), the percentage of patients with metastatic disease at diagnosis who had PSA > 20 increased from 54% in 2004 versus the present 72% in 2014 – a 1.3 fold increase in proportion. In the lowest risk group (PSA < 4), the proportion resenting with metastatic disease also experienced a proportional increase: from 0.92% in 2004 to 2.65% in 2014 – a 2.88 fold increase.

While PSA is indeed a rough metric for prostate cancer progression, there is little change that these results were from happenstance. The higher disease burden at diagnosis (and treatment) correlates closely with the 2008 and 2012 grade D recommendations. Although further studies are required to establish a causative relationship, this reverse stage migration in the contemporary PSA screening era raises concern for biochemical recurrence, metastatic disease presentation, and prostate cancer specific mortality.

Authors: Jared P. Schober*, Kristian D. Stensland, Karim Hamawy, Alireza Moinzadeh, David Canes

Presented by: Jared Schober, MD, Lahey Hospital & Medical Center

Written By: Linda Huynh (BS), an assistant research specialist from the University of California, Irvine, on behalf of

at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA