Advance Access publication on July 25, 2012.
JNCI | Articles 1335
Published by Oxford University Press 2012.
temporal trends in cause of Death Among Swedish and US Men
with Prostate cancer
Mara M. Epstein, Gustaf Edgren, Jennifer R. Rider, Lorelei A. Mucci, Hans-Olov Adami
Manuscript received March 07 , 2012; revised May 24, 2012; accepted May 30, 2012.
Correspondence to: Mara Meyer Epstein, ScD, Department of Epidemiology, Harvard School of Public Health, 677 Huntington Ave, 9th floor, Boston, MA
02115 (e-mail: email@example.com).
Background A growing proportion of men diagnosed with localized prostate cancer detected through prostate-specific anti-
gen 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.
Methods 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.
Results 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 inci-
dence 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.
Conclusions 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 life-
style, interventions that target lifestyle factors should be integrated into prostate cancer management.
J Natl Cancer Inst 2012;104:1335–1342
Over the past few decades in most Western countries, the prob-
ability that a man who was recently diagnosed with prostate can-
cer will die of this disease has decreased substantially. Although
the incidence of prostate cancer has increased greatly in these
countries, prostate cancer mortality has not (1,2). Most, if not all,
of the increased incidence of prostate cancer can be ascribed to
widespread prostate-specific antigen (PSA) screening, which has
resulted in a higher proportion of men diagnosed with localized
disease and overdiagnosis of nonlethal cancer (3,4). A 2009 study
of men older than 65 years in the US Surveillance, Epidemiology,
and End Results (SEER) program reported that men with conser-
vatively managed, localized, and well-to-moderately differentiated
prostate cancer had a 8%–9% risk of dying from prostate cancer
within 10 years of diagnosis (5). According to the SEER database
(6), 81% of men diagnosed with prostate cancer in 2001–2007 had
localized disease. Thus, most newly diagnosed men will ultimately
die from a cause other than their prostate cancer, and the risk of
dying from another cause may be modifiable by lifestyle inter-
vention. However, the temporal trends in specific causes of death
among prostate cancer patients are not well described. Such infor-
mation could guide preventive measures that target the overall
health of prostate cancer patients.
Many patients with low-risk prostate cancer undergo curative
treatment with little or no survival benefit. Treatment for localized
prostate cancer also carries considerable reductions in quality of
life (7–9). Given the older age at diagnosis of most patients with
localized prostate cancer, these men are at substantial risk of
dying from a constellation of chronic conditions. As such, lifestyle
interventions directed toward reducing the risk of competing
causes of death may improve the overall survival of these patients
We used data from population-based databases to perform
detailed analyses of the distribution of causes of death among men
diagnosed with prostate cancer in Sweden and the United States, two
countries with some of the highest incidence rates in the world (83.8
and 95.5 per 100 000 persons, respectively, in 2008) (11). To better
assess temporal trends, we analyzed the distribution of specific causes
of death by follow-up time, year of diagnosis, and age at diagnosis.
by guest on December 25, 2015
Vol. 104, Issue 17 | September 5, 2012
1342 Articles | JNCI
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This work was supported by Karolinska Institutet Distinguished Professor
Award (Dnr: 2368/10-221 to HOA); National Institutes of Health National
Cancer Institute research training grant (R25 CA098566 to MME); and a post-
doctoral grant from Svenska Sällskapet för Medicinsk Forskning (to GE).
The study sponsors did not have any role in the design of this study, analysis or
interpretation of the data, the writing of this article, or the decision to submit
the article for publication.
Affiliations of authors: Department of Epidemiology, Harvard School
of Public Health, Boston, MA (MME, GE, JRR, LAM, HOA); Channing
Laboratory, Department of Medicine, Brigham and Women’s Hospital and
Harvard Medical School, Boston, MA (MME, JRR, LAM); Department of
Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm,
Sweden (GE, HOA).
by guest on December 25, 2015