Temporal Changes in the Clinical Approach to Diagnosing Prostate Cancer

Prostate cancer has become an extremely important public health problem in the United States. The disease is the second leading cause of cancer-related death among US men; in 2010, an estimated 217 030 new cases of prostate cancer in the United States were diagnosed, and 32 050 died as a direct result of the disease (1). The cost of treating prostate cancer has been estimated to rise to $16.85 billion in 2020, representing a 28% increase in expenditures from today’s cost of $11.85 billion (2). Despite these sobering statistics, a majority of prostate cancers currently diagnosed would never have been diagnosed were it not for the introduction of prostate-specific antigen (PSA)-based prostate cancer screening. A fundamental challenge of PSA-based prostate cancer screening is that many of the cancers diagnosed are destined to never cause harm or death to the patient. If these indolent tumors are treated, there is no health benefit, but the associated costs and morbidity are substantial. In this chapter, we review the temporal changes in clinical and in other practices that have contributed to a previously unseen major migration in the type of prostate cancer diagnosed over the past several decades, including the impact of PSA testing and other techniques of diagnosis and staging. It is these changes that have led to the current situation in which a large number of men with prostate cancer at very low risk of progression, morbidity, and mortality are diagnosed.