91000132576Ann EpidemiolAnn EpidemiolAnnals of epidemiology1047-27971873-258529678312608030510.1016/j.annepidem.2018.03.001HHSPA982729ArticleStage-specific incidence rates and trends of prostate cancer by age, race, and ethnicity, United States, 2004-2014LiJunMD, PhDa*SiegelDavid A.MD, MPHabKingJessica B.MPHc Epidemiology and Applied Research Branch, Division of Cancer and Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA Epidemic Intelligence Service, CDC, Atlanta, GA Cancer Surveillance Branch, Division of Cancer and Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA Corresponding author. Epidemiology and Applied Research Branch, Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy, Mail Stop F-76, Atlanta, GA 30341. Tel.: 770-488-3030; fax: 770-488-4639, ffa2@cdc.gov (J. Li).27720180632018520180782018285328330Purpose:

Current literature shows different findings on the contemporary trends of distant-stage prostate cancer incidence, in part, due to low study population coverage and wide age groupings. This study aimed to examine the stage-specific incidence rates and trends of prostate cancer by age (5-year grouping), race, and ethnicity using nationwide cancer registry data.

Methods:

Data on prostate cancer cases came from the 2004—2014 United States Cancer Statistics data set. We calculated stage-specific incidence and 95% confidence intervals by age (5-year age grouping), race, and ethnicity. To measure the changes in rates over time, we calculated annual percentage change (APC).

Results:

We identified 2,137,054 incident prostate cancers diagnosed during 2004—2014, with an age-adjusted incidence rate of 453.8 per 100,000. Distant-stage prostate cancer incidence significantly decreased during 2004—2010 (APC = −1.2) and increased during 2010—2014 (APC = 3.3). Significant increases in distant prostate cancer incidence also occurred in men aged older than or equal to 50 years except men aged 65—74 and older than or equal to 85 years, in men with white race (APC = 3.9), and non-Hispanic ethnicity (APC = 3.5).

Conclusions:

Using data representing over 99% of U.S. population, we found that incidence rates of distant-stage prostate cancer significantly increased during 2010—2014 among men in certain ages, in white, and with non-Hispanic ethnicity.

Prostate cancerCancer incidenceCancer stageBackground

With the introduction of prostate-specific antigen (PSA) testing in the mid-1980s, the incidence rate of distant-stage prostate cancer has decreased more than 60% during the last two decades [1]. Concluding that harms from PSA-based screening outweighed benefits, the United States Preventive Services Task Force recommended against routine PSA-based screening for men older than or equal to 75 years of age in 2008 and all ages in 2012 [2]. Studies have consistently shown that PSA testing prevalence and localized/regional prostate cancer incidence rates declined following these recommendations [3—6]. However, current literature shows different findings on the contemporary trends of distant-stage prostate cancer incidence. These differences might be because of low population coverage (≤28%) and wide age groupings [3,7,8].

Objective

To examine the stage-specific incidence rates and trends of prostate cancer by age (5-year grouping), race, and ethnicity using nationwide cancer registry data.

Methods and findings

Data on prostate cancer cases came from the United States Cancer Statistics (USCS) data set, which includes the National Program of Cancer Registries and Surveillance, Epidemiology, and End Results (SEER) programs. Incidence data for all registries except Nevada met USCS publication criteria (http://www.cdc.gov/cancer/npcr/standards.htm) during 2004—2014, and represented 99.1% of the U.S. population. We identified prostate cancer cases using the International Classification of Diseases for Oncology, Third Edition site code C619 and behavior code 3. We excluded 1160 autopsy or death certificate-only cases (0.05%) and 72,232 nonmicroscopically confirmed cases (3.27%). We calculated stage-specific (localized, regional, distant, and unstaged) incidence and 95% confidence intervals by age (5-year age grouping), race (white, black, Asian/Pacific Islander, and American Indian/Alaska Native), and ethnicity (Hispanic and non-Hispanic) using SEER*Stat. Rates for all variables except age were age standardized to the 2000 U.S. standard population. To measure the changes in rates over time, we calculated annual percentage change (APC) using Joinpoint regression software. A maximum of two join points were used to determine a change of direction in trends during our study period. APCs were considered to be statistically significant if P <.05.

We identified 2,137,054 incident prostate cancers diagnosed during 2004—2014. The age-adjusted incidence rate was 453.8 per 100,000. Of these cases, 80% were localized, 10% were regional, 4% were distant, and 5% were unstaged (data not shown). Table 1 shows cancer stage-specific incidence rates and trends by age, race, and ethnicity. For localized- and regional-stage prostate cancers, incidence rates were stable during 2004—2007 and significantly declined during 2007—2014. In contrast, distant-stage prostate cancer incidence significantly decreased during 2004—2010 (APC = −1.2) and increased during 2010—2014 (APC = 3.3). Significant increases in distant prostate cancer incidence also occurred in men aged older than or equal to 50 years except men aged 65—74 and older than or equal to 85 years, and in men with white race (APC = 3.9), or non-Hispanic ethnicity (APC = 3.5).

Discussion

Using data representing over 99% of U.S. population, we found that incidence rates of distant-stage prostate cancer significantly increased during 2010—2014 among men aged older than or equal to 50 years. Stratified analyses by age, race, and ethnicity suggest that this increase occurred among men of white race, non-Hispanic ethnicity, and men aged 50—64 and 75—84 years.

Two previously published SEER studies showed stable trends of distant-stage prostate cancer among men aged less than 75 years [3,5]. However, three other SEER studies reported increasing trends among men aged 45—64, 50—69, and 45—69 years, respectively [7,9,10]. Past studies reported either increasing or decreasing trends for men aged older than or equal to 75 years [5,8,9]. These studies were smaller and did not include the 2014 cancer incidence data. Using the 2004—2014 USCS data, we found a significant increase in distant-stage prostate cancer incidence among men aged 50—64 and 75—84 years. A significant increase was also observed among white men, which confirms findings reported by Dalela et al. [9] Despite the differences in prostate cancer screening recommendations among major medical organizations [2,11,12], studies have shown that prostate cancer incidence and PSA-based screening rates declined after the United States Preventive Services Task Force issued the “D” recommendations for prostate cancer screening in 2012 [3—5]. Because of the long natural history of prostate cancer and only two additional years’ cancer incidence data after 2012 available for analysis, long-term studies are needed to discern increased rates of distant cancer were a result of decreased screening. These studies will help to inform the development of future prostate cancer screening recommendations.

This study has at least five limitations. First, full case ascertainment may impede timely reporting of prostate cancer cases; however, delayed reporting likely caused underestimation of rates and increasing trends in the recent years. Second, trend analyses, a function of time, may be affected by outliers in a given year. Third, only two years of incidence data after 2012 were available for analysis. Fourth, Joinpoint models choose the best fit segmented line with the smallest number of join points through several years of data. The pattern of the trend is sensitive to the number and location of join point and may partially contribute to differences in trends from previous studies. Last, we did not examine Gleason scores because they are not currently available in the USCS data set.

Disclosure: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

No financial conflict of interest for all authors and no funding sources claimed.

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Stage-specific incidence rates and trends of prostate cancer by age, race, and ethnicity, United States, 2004—2014

CharacteristicsCountRate*95% CIYearsAPC1†95% CIYearsAPC2†95% CI
Total2,137,054453.8453.2—454.42004—20073.7−3.7 to 11.72007—2014−7.5‡−9.3 to −5.6
Stage
    Localized1,708,064362.5361.9—363.02004—20074.3−3.8 to 13.12007—2014−8.6‡− 10.6 to −6.6
    Regional233,24546.346.1—46.52004—20072.9−4.1 to 10.52007—2014−3.2‡−5.0 to ∑1.3
    Distant84,95419.519.4—19.72004—2010− 1.2‡−2.0 to −0.32010—20143.3‡1.6 to 5.0
    Unstaged110,79125.525.3—25.62004—2014−4.4‡−6.1 to −2.6
Localized
    Age
        50—54 years126,885109.9109.3—110.52004—20093.4−0.2 to 7.22009—2014−8.9‡−12.1 to −5.6
        55—59 years240,578235.4234.5—236.32004—20083.5−0.9 to 8.02008—2014−8.1‡−10.2 to −5.9
        60—64 years327,540394.7393.4—396.12004—20076.3− 1.9 to 15.22007—2014−7.8‡−9.7 to −5.8
        65—69 years373,529594.2592.3—596.12004—20075.3−3.9 to 15.32007—2014−7.8‡−10.0 to −5.5
        70—74 years300,278643.9641.6—646.22004—20074.1−4.3 to 13.32007—2014−8.9‡−11.0 to −6.9
        75—79 years202,941575.0572.5—577.52004—20072.6−5.7 to 11.62007—2014−10.1‡−12.1 to −8.1
        80—84 years95,107384.3381.8—386.72004—2007−0.6−9.0 to 8.72007—2014−11.6‡−13.7 to −9.5
        85 + years41,206216.7214.7—218.82004—2007−2.8− 10.6 to 5.62007—2014−13.2‡−15.2 to −11.3
    Race
        White1,380,775341.5340.9—342.02004—20074.3−4.0 to 13.42007—2014−9.1‡−11.1 to −7.1
        Black244,065544.0541.8—546.32004—20081.5−2.2 to 5.22008—2014−7.8‡−9.6 to −6.0
        API6296181.5176.6—186.42004—2009−2.2−5.6 to 1.32009—2014−11.7‡−14.7 to −8.5
        AIAN32,356182.6180.5—184.62004—2011−5.1‡−7.5 to —2.62011—2014−15.0‡−22.8 to −6.4
    Ethnicity
        Non-Hispanic1,605,664368.7368.1—369.22004—20074.5−3.8 to 13.52007—2014−8.6‡−10.6 to −6.5
        Hispanic102,161293.6291.7—295.52004—20080.0−3.2 to 3.32008—2014−9.4‡−10.9 to −7.8
Regional
    Age
        50—54 years24,58621.321.0—21.62004—20090.9−2.9 to 4.82009—2014−6.0‡−9.5 to −2.3
        55—59 years44,33343.443.0—43.82004—2010−0.6−3.5 to 2.32010—2014−5.7‡−10.7 to −0.4
        60—64 years57,25869.068.4—69.62004—20073.3−4.2 to 11.32007—2014−4.1‡−6.0 to −2.1
        65—69 years56,59390.089.3—90.82004—20101.0− 1.6 to 3.72010—2014−5.7‡−10.3 to −1.0
        70—74 years30,33265.064.3—65.82004—20074.4−2.2 to 11.52007—2014−1.5−3.2 to 0.2
        75—79 years11,65133.032.4—33.62004—2014−0.8− 1.8 to 0.3
        80—84 years514620.820.2—21.42004—2014−2.7‡−4.3 to −1.1
        85 + years334617.617.0—18.22004—2014−3.7‡−5.2 to −2.2
    Race
        White196,13845.745.5—45.92004—20073.0−4.2 to 10.92007—2014−3.3‡−5.1 to −1.4
        Black28,28856.355.6—57.02004—2014−1.6‡−2.6 to −0.5
        API94723.221.6—24.82004—2014−3.2‡−5.9 to −0.4
        AIAN528026.725.9—27.42004—20111.0−2.0 to 4.12011—2014−9.5−19.1 to 1.2
    Ethnicity
        Non-Hispanic218,89247.247.0—47.52004—20073.1−4.1 to 10.92007—2014−3.1‡−5.0 to −1.2
        Hispanic14,33636.535.8—37.12004—2014−2.1‡−3.0 to −1.2
Distant
    Age
        50—54 years44803.93.8—4.02004—20142.0*0.9 to 3.0
        55—59 years84848.3I2004—20142.8*1.5 to 4.1
        60—64 years11,89814.314.1—14.62004—2008−2.1−5.9 to 1.92008—20143.5‡1.3 to 5.7
        65—69 years13,31021.220.8—21.52004—2014−0.4− 1.5 to 0.7
        70—74 years12,84727.527.1—28.02004—2008−2.1−5.6 to 1.52008—20141.90.0 to 3.9
        75—79 years12,40535.134.5—35.82004—2011−1.4*−2.4 to —0.42011—20145.1‡1.2 to 9.1
        80—84 years11,37245.945.1—46.82004—2010−2.4*−4.4 to —0.22010—20144.2‡0.1 to 8.5
        85 + years10,15853.452.4—54.52004—2014−0.5− 1.7 to 0.8
    Race
        White65,70917.517.4—17.72004—2010−0.8− 1.8 to 0.12010—20143.9‡2.1 to 5.7
        Black16,06241.140.4—41.82004—2010−3.3*−4.9 to −1.82010—20140.3−2.6 to 3.4
        API47615.814.2—17.42004—2014−0.4−3.3 to 2.6
        AIAN200512.612.0—13.22004—2014−1.2−3.2 to 0.8
    Ethnicity
        Non-Hispanic78,39919.419.3—19.62004—2010−1.1*− 1.9 to −0.32010—20143.5‡1.9 to 5.1
        Hispanic655320.920.4—21.52004—2011−2.9*−3.9 to −1.92011—20142.9−1.0 to 7.0
Unstaged
    Age
        50—54 years45553.93.8—4.12004—20140.7− 1.5 to 3.0
        55–59 years94779.39.1 —9.52004—20141.0−0.8 to 2.9
        60–64 years15,08218.217.9—18.52004—20093.3− 1.5 to 8.22009—2014−3.9−8.3 to 0.8
        65–69 years19,87931.631.2—32.12004—2014−1.1−3.4 to 1.1
        70–74 years20,36243.743.1—44.32004—20100.4−4.6 to 5.62010—2014−9.4‡−17.6 to −0.5
        75–79 years18,53952.551.8—53.32004—20071.9−9.5 to 14.82007—2014−7.9‡−10.8 to −4.9
        80—84 years13,16253.252.3—54.12004—2007−2.0− 11.8 to 9.02007—2014−10.9‡−13.4 to −8.3
        85 + years973551.250.2—52.22004—2007−3.6−13.1 to 7.02007—2014−12.9‡−15.3 to −10.4
    Race
        White76,69920.520.3—20.62004—2014−7.0*−8.9 to −5.2
        Black14,99539.238.5—39.92004—2014−5.0*−6.6 to −3.3
        API58720.919.1—22.92004—2014−4.6*−7.4 to −1.6
        AIAN234115.014.4—15.72004—20106.3−0.2 to 13.42010—2014−9.3−19.5 to 2.2
    Ethnicity
        Non-Hispanic100,59924.924.7– 25.02004–2014−4.4‡−6.1 to −2.7
        Hispanic997533.532.8– 34.22004–20095.0−3.7 to 14.52009–2014− 12.3‡−19.6 to −4.3

APC = Annual Percentage Change; API = Asian or Pacific Islander; AIAN = American Indian/Alaska Native; Cl = confidence interval.

Rates are per 100,000 and rates for all variables except age are age-adjusted to the 2000 U.S. Standard Population (19 age groups—Census P25–1130).

Trends were measured with annual percentage change in rates and were considered to increase or decrease if P < .05; otherwise trends were considered stable.

P < .05.

CDC’s National Program of Cancer Registries and the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program.