Globally, there are an estimated 1,600,000 new cases and 366,000 prostate cancer deaths annually. An estimated 1 in 6 males in the US will be diagnosed with clinically evident prostate cancer in their lifetime. 1 of 34 will die from it. Autopsy studies have shown that clinically silent prostate cancer is common and approximately 60% of men will have prostate cancer by age 80.

Survival Rates Improve

Over time, it has been recognized that detecting prostate cancer at an early stage when it is low volume and confined to the gland can result in cure rates near 100%. However, the current methods for screening, usually starting with a blood test for prostate specific antigen (PSA), are less than perfect and can result in unnecessary biopsies, excess morbidity, and overtreatment of cancers that do not pose a mortality risk. For this reason, many medical guidelines suggest a shared decision model, where the doctor and patient discuss the benefits and risks associated with screening that enables the patient to make an individualized, informed decision about screening.  

One exciting development is the increased use of Magnetic Resonance Imaging (MRI) in the evaluation of potential prostate lesions. As the strength and resolution of the MRI equipment has improved, so too has the ability to detect prostate cancer and even to estimate the aggressiveness of the tumor. The American College of Radiology has released an updated version of a 5-point PIRADS assessment scale that is analogous to the BiRADS score used to screen for breast cancer. Assessments range from PIRADS 1 (very low likelihood of significant prostate cancer) to PIRADS 5 (very high likelihood of significant cancer). MRI can also be used to guide biopsy, resulting in better diagnostic yield and to stage the extent of the tumor. MRI can also play a significant role in monitoring for recurrence after treatment or during active surveillance of non-aggressive tumors.

Risk Assessment Re-evaluated

Survival rates have gradually improved and over 3 million men are survivors of prostate cancer in the US. By 2024, it is estimated that survivors will exceed 4 million. The average annual percent change in mortality rates due to prostate cancer was -2.9 between 2006 and 2015. Today, prostate cancer survivors often have a higher risk of death due to non-cancer causes, such as heart disease, than they do from prostate cancer. Surgical removal, radiation, and watchful waiting remain the standard courses of therapy while robotics and minimally invasive surgical techniques have made great strides in reducing morbidity. A newer staging system (2017) from the American Joint Committee on Cancer and the Union for International Cancer Control now include the anatomical extent of disease, pre-treatment PSA level, and histologic grade (Gleason score) to group patients into prognostic groups. As this information is incorporated into risk assessment, it will result in more accurate evaluation of future risk.   

Author

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Dr. Richard Braun, Chief Medical Director at SCOR Global Life in the Americas.