Temporal Trends in Cause of Death Among Swedish and US Men with Prostate Cancer

ScD, Department of Epidemiology, Harvard School of Public Health, 677 Huntington Ave, 9th floor, Boston, MA 02115. .
Journal of the National Cancer Institute (Impact Factor: 12.58). 07/2012; 104(17):1335-42. DOI: 10.1093/jnci/djs299
Source: PubMed


A growing proportion of men diagnosed with localized prostate cancer detected through prostate-specific antigen testing are dying from causes other than prostate cancer. Temporal trends in specific causes of death among prostate cancer patients have not been well described.

We analyzed causes of death among all incident prostate cancer cases recorded in the nationwide Swedish Cancer Registry (1961-2008; n = 210 112) and in the US Surveillance, Epidemiology, and End Results Program (1973-2008; n = 490 341). We calculated the cumulative incidence of death due to seven selected causes that accounted for more than 80% of the reported deaths (including ischemic heart disease and non-prostate cancer) and analyzed mortality trends by calendar year and age at diagnosis and length of follow-up.

During follow-up through 2008, prostate cancer accounted for 52% of all reported deaths in Sweden and 30% of reported deaths in the United States among men with prostate cancer; however, only 35% of Swedish men and 16% of US men diagnosed with prostate cancer died from this disease. In both populations, the cumulative incidence of prostate cancer-specific death declined during follow-up, while the cumulative incidences of death from ischemic heart disease and non-prostate cancer remained constant. The 5-year cumulative incidence of death from prostate cancer among all men was 29% in Sweden and 11% in the United States.

In Sweden and the United States, men diagnosed with prostate cancer are less likely to die from prostate cancer than from another cause. Because many of these other causes of death are preventable through changes in lifestyle, interventions that target lifestyle factors should be integrated into prostate cancer management.

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    • "This study demonstrated a crude one-year survival rate of 95% with variations related to age, which is similar to estimates from French cancer registries (92% one-year overall survival, and a specific survival rate of 96%) [15]. Causes of death other than PCa were reported for 80% of deceased patients in the United States and 65% of deceased patients in Sweden [16]. Patients with PCa, especially with metastatic disease, presented a higher risk of death by suicide or cardiovascular disease than the general population [17]. "
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    ABSTRACT: Background This very large population-based study investigated outcomes after a diagnosis of prostate cancer (PCa) in terms of mortality rates, treatments and adverse effects. Methods Among the 11 million men aged 40 years and over covered by the general national health insurance scheme, those with newly managed PCa in 2009 were followed for two years based on data from the national health insurance information system (SNIIRAM). Patients were identified using hospitalisation diagnoses and specific refunds related to PCa and PCa treatments. Adverse effects of PCa treatments were identified by using hospital diagnoses, specific procedures and drug refunds. Results The age-standardised two-year all-cause mortality rate among the 43,460 men included in the study was 8.4%, twice that of all men aged 40 years and over. Among the 36,734 two-year survivors, 38% had undergone prostatectomy, 36% had been treated by hormone therapy, 29% by radiotherapy, 3% by brachytherapy and 20% were not treated. The frequency of treatment-related adverse effects varied according to age and type of treatment. Among men between 50 and 69 years of age treated by prostatectomy alone, 61% were treated for erectile dysfunction and 24% were treated for urinary disorders. The frequency of treatment for these disorders decreased during the second year compared to the first year (erectile dysfunction: 41% vs 53%, urinary disorders: 9% vs 20%). The frequencies of these treatments among men treated by external beam radiotherapy alone were 7% and 14%, respectively. Among men between 50 and 69 years with treated PCa, 46% received treatments for erectile dysfunction and 22% for urinary disorders. For controls without PCa but treated surgically for benign prostatic hyperplasia, these frequencies were 1.5% and 6.0%, respectively. Conclusions We report high survival rates two years after a diagnosis of PCa, but a high frequency of PCa treatment-related adverse effects. These frequencies remain underestimated, as they are based on treatments for erectile dysfunction and urinary disorders and do not reflect all functional outcomes. These results should help urologists and general practitioners to inform their patients about outcomes at the time of screening and diagnosis, and especially about potential treatment-related adverse effects.
    Full-text · Article · Jun 2014 · BMC Urology
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    • "This suggests that we may have underestimated the risk of screen-detected cancer. Second, prostate cancer mortality has historically been higher in Sweden – around 5% of male deaths compared to less than 3% in the US [28]. Moreover, recent advances in treatment have led to improvements in survival leading to a lower risk of death [29]. "
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    ABSTRACT: Prostate cancer screening depends on a careful balance of benefits, in terms of reduced prostate cancer mortality, and harms, in terms of overdiagnosis and overtreatment. We aimed to estimate the effect on overdiagnosis of restricting prostate specific antigen (PSA) testing by age and baseline PSA. Estimates of the effects of age on overdiagnosis were based on population based incidence data from the US Surveillance, Epidemiology and End Results database. To investigate the relationship between PSA and overdiagnosis, we used two separate cohorts subject to PSA testing in clinical trials (n = 1,577 and n = 1,197) and a population-based cohort of Swedish men not subject to PSA-screening followed for 25 years (n = 1,162). If PSA testing had been restricted to younger men, the number of excess cases associated with the introduction of PSA in the US would have been reduced by 85%, 68% and 42% for age cut-offs of 60, 65 and 70, respectively. The risk that a man with screen-detected cancer at age 60 would not subsequently lead to prostate cancer morbidity or mortality decreased exponentially as PSA approached conventional biopsy thresholds. For PSAs below 1 ng/ml, the risk of a positive biopsy is 65 (95% CI 18.2, 72.9) times greater than subsequent prostate cancer mortality. Prostate cancer overdiagnosis has a strong relationship to age and PSA level. Restricting screening in men over 60 to those with PSA above median (>1 ng/ml) and screening men over 70 only in selected circumstances would importantly reduce overdiagnosis and change the ratio of benefits to harms of PSA-screening.
    Full-text · Article · Feb 2014 · BMC Medicine
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    • "No difference was observed between surface and underground miners. As men with prostate cancer are more likely to die from another cause (Epstein et al, 2012), mortality data are probably less accurate than incidence data when studying risk of prostate cancer. As mines operate 24 Â 7, workers are required to do regular night shifts. "
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    ABSTRACT: Background: In a cohort of goldminers, we estimated cancer mortality and incidence, for both surface and underground workers, and we examined the hypothesis that (underground) mining may be protective against prostate cancer. Methods: Standardised mortality and incidence ratios (SMRs and SIRs) and 95% confidence intervals (CI) were calculated to compare cancer mortality and incidence of former goldminers with that of the general male population. Internal comparisons on duration of underground work were examined using Cox regression. Results: During 52 608 person-years of follow-up among 2294 goldminers, 1922 deaths were observed. For any cancer, mortality was increased for the total group of miners (SMR=1.27, 95% CI 1.16–1.39). In the Cox models, lung cancer mortality and incidence were particularly increased among underground miners, even after adjustment for smoking. The SMR for prostate cancer suggested a lower risk for underground miners, whereas incidence of prostate cancer was significantly increased (SIR=1.31, 95% CI 1.07–1.60) among underground miners. Conclusion: Overall cancer mortality and incidence was higher among Western Australian goldminers compared with the general male population, particularly for underground mining. This study does not support the hypothesis that miners have a decreased risk of prostate cancer.
    Full-text · Article · Apr 2013 · British Journal of Cancer
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