After years of decline, more men have been diagnosed with prostate cancer in recent years.
According to the American Cancer Society, prostate cancer cases have declined over the past several years, but the number of new cases has increased by 3% annually since 2014. The number of men diagnosed with advanced-stage prostate cancer has increased by 5% annually in recent years.
Dr. William Dahut, chief scientific officer for the American Cancer Society, said it's particularly troubling to see the increase in people with more advanced stages of the disease.
“We are certainly seeing an increase in the number of men being diagnosed with prostate cancer,” says Dahut. “But what's really worrying is that this is due to men being diagnosed with more advanced disease.”
In an interview with Chief Healthcare Executive®, Dahut talks about some troubling trends in prostate cancer. He also talks about the need for doctors and health systems to discuss the disease more with their patients. And he says there needs to be better education about some of the misconceptions about prostate cancer screening.
While the Cancer Society promotes the importance of shared decision-making regarding prostate cancer, Dahut says he is concerned that fewer men are getting screened, which may contribute to higher rates of men being diagnosed with more aggressive prostate cancer.
According to projections from the American Cancer Society, more than 35,000 men are expected to die from prostate cancer in 2024. “That’s not a small number,” Dahut says.
Deaths from prostate cancer fell by half from 1993 to 2013, but the rate has stabilized in recent years. Dahut says this may be because more men with later stages of prostate cancer are being diagnosed.
“There are a lot of men whom prostate cancer will never harm, and I think we should think about that in how we intervene,” he says. “But then, you know, a lot of men are still dying from prostate cancer.”
Since September is Prostate Cancer Awareness Month, Dahut says he hopes there will be recognition of the need for more discussion, education and screening on the topic. (Watch an excerpt of our conversation with Dr. Dahut in this video. Story continues below.)
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Prostate cancer screening has become a complex issue in recent years.
The US Preventive Services Task Force said in 2018 that periodic screening through a blood test should be an individual decision for men between the ages of 55 and 69.
“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 suffer the potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment-related complications, such as incontinence and erectile dysfunction.”
The task force also said in its 2018 guidelines that it does not recommend any screening for men age 70 and older. The task force is in the process of revising its recommendations.
Today, Dahut says there should be more discussion with patients, and better understanding among doctors as well.
“I think our primary care doctors were told that this test is harmful,” Dahut says. “And, you know, it's hard to take it out of one's work pattern.”
Dahut would like to see more doctors and health systems have conversations with patients, especially those at higher risk, such as learning about their family history.
He also said that after discussion and investigation, surgery was not required.
“At any time, if a man decides he doesn't want to go ahead, he can stop the procedure,” he says. “So I think there was this concern that once a man gets a PSA test, he's kind of on a one-way street and the next thing you know, he has his prostate removed, and two weeks later he's impotent and incontinent.”
But he stressed that even a positive diagnosis after screening does not necessarily mean surgery is needed straight away.
“Informed decisions can be made during this time, including active surveillance, which allows men whose prostate cancer appears indolent in the early stages to be watched very closely, and treatment may either be avoided or delayed, or may never be needed at all,” he says.
Clearing up misunderstandings
Dahut suggests that more people would be willing to get tested if there were no misconceptions about it.
According to an American Cancer Society survey, many men don't know the first step is a blood test. Three out of five men (60%) incorrectly think the first screening for prostate cancer is a digital rectal exam.
According to the survey, nearly half (49%) of people said they would be more willing to talk to a doctor if they knew the initial screening was a simple blood test. The initial screening usually involves testing the level of prostate-specific antigen (PSA) in the blood.
More and more men should be made aware that erectile dysfunction can be a sign of prostate cancer. The survey found that 56% of men were unaware of this connection.
Dahut says most men with erectile dysfunction don't have prostate cancer. But seeing a urologist is still a good step, and Dahut says patients should get a blood test for prostate cancer.
Men who have a family history of prostate cancer should get tested, as they are at a higher risk.
“Prostate cancer is probably the disease that's most closely related to family history,” says Dahut. “It actually has a very high genetic component.”
Patients also have better treatment options now than they did 20 to 30 years ago, he said.
Most surgeries for prostate cancer are now performed by robots, and the advent of robotic surgery “has been a great equalizer,” Dahut says.
“I think it has increased the ability to provide good care in many places,” he says.
Patients also have other options available besides surgery, including radiation therapy, which has improved over time.
“I think there's a lot of fear that these treatments could cause incontinence, potentially, or impotence,” he says. “You know, these treatments are better than ever.”
Steps for doctors and health systems
Dahut says more patients should talk to their doctors about prostate cancer testing.
Many people, including physicians, believe that prostate cancer screening is more harmful than beneficial. And that has impacted the number of men who get tested, Dahut says.
“Our concern is that a lot of people are just being told not to do it, and I think overall that's harmful,” he says.
Although he advocates for making decisions together with patients and respects those who say they don't want to be tested, Dahut says doctors can provide more and better information.
Some health systems have required doctors to talk about prostate cancer screening, including requiring that the conversation be incorporated into the electronic health record. Dahut cited Duke University and Washington University in St. Louis as organizations that have taken this step, leading to a “dramatic increase” in screening.
“By mandating at least having these discussions in the health record, I think the number of people getting screened would increase substantially,” he says.
Many men may choose not to be screened or to only be monitored, even if they are found to be at high risk. But he believes more screening will allow more people to be diagnosed in the early stages.
Dahut says greater awareness about screening, dispelling myths, and more conversations with patients could make a difference.
“When these discussions take place, I think it has the potential to really improve outcomes,” he says.