Matthew Cooperberg, MD, reacts to 2025 ACS prostate cancer data

In this video, Matthew R. Cooperberg, MD, MPH, highlights key prostate cancer data from the American Cancer Society’s Cancer Statistics, 2025 report and considers the causes of the rise in incidence and mortality. Cooperberg is a professor of urology and epidemiology & biostatistics at the University of California, San Francisco Helen Diller Family Comprehensive Cancer Center as well as the chief of urology at the San Francisco VA medical center.

Video Transcript:

These are, first of all, incredibly helpful data, and it's wonderful that the American Cancer Society puts so much effort into compiling them every year. Every year in January, everybody's waiting to see what the updates are going to look like. It's been a really great source of insights into the trends over time that we've seen in, of course, all cancers—we're focusing on prostate today specifically—but it's really an amazing resource. There's a paper published every year and a companion, longer document Cancer Facts and Figures that I think defines a lot of what we do in terms of year-to-year epidemiology in the US for all cancers.

The prostate update this year is that the expectation for 2025 is over 313,000 men will be diagnosed with prostate cancer, and over 35,000 will die of the disease. These numbers are going up, and they're going up at a significant clip. Every year these data are updated. There's a lot of discussion about what is driving the trends. It really goes to the complexity of tracking prostate cancer epidemiology in terms of both incidence and mortality for the reasons that incidence of prostate cancer is so tightly tied up with screening and how hard we are looking for prostate cancer and how we're defining prostate cancer. Mortality, in turn, typically takes literally decades after diagnosis to occur when it is going to occur. So, when we look at the incidence data year to year, what we're really looking at is intensity of screening and diagnostic endeavors, which start at the primary care level. When we look at the mortality data, we're looking at the effects of policy decisions that we made years ago and in some cases, decades ago.

Of course, the elephant in the room when we talk about these trends over the last 20 years in prostate cancer is screening patterns and the impact of the US Preventative Services Task Force in particular over the years. The trend, as we've seen it unfold, is that when prostate cancer screening first hit the marketplace and hit attention in the early 2000s, prostate cancer incidence rates skyrocketed because we identified all these prevalent cases. All these men who had been living with asymptomatic prostate cancer in the pre-screening era, we suddenly found all these cancers, and there was a huge spike in incidence to the highest rates we have ever seen before or since. Then things stabilized throughout the 90s and 2000s as screening became more popular. Then, of course, with recognition of overtreatment and some very deeply flawed interpretations of the emerging trial literature, the US Preventive Services Task Force recommended in 2008 that we stopped screening men over 75, and in 2012 they said we should stop screening all men, period. They had a lot of prevaricating language in the guideline, but at the end of the day, that's what they said, and that is what primary care docs interpreted. Literally, overnight, screening rates fell 25%. The incidence rates following 2012 fell to the lowest level we've seen since the 1980s. It's not because prostate cancer disappeared, it's because we literally stopped looking for it. Then, in 2018, at least in part, recognizing that we are now doing active surveillance and we're trying not to treat low-risk prostate cancer. We got this C recommendation from the Task Force, which is saying, "Well, we still don't really recommend this, but you should have a conversation with men". The incidence rate is going up again because screening rates have started coming up again. I think a lot of us have the sense that now we really know how to do smarter screening and treatment to a much better extent than we did before.

So, that's the incidence story. In the meantime, the mortality story, death rates for prostate cancer had been falling consistently since the 1990s, the early years of the screening era. They fell throughout the 90s and 2000s at a faster velocity than any other cancer except lung cancer. We know the setting in the case of lung cancer, this is obviously because of smoking cessation. Less smoking across the population, that is clearly what drives the mortality drop for lung cancer. In the case of prostate cancer, it was controversial for a lot of years how much of this could be attributed directly to screening. The best analyzes from the CISNET group suggests that it's at least a third, and then another third can be attributed to improvements in treatment for high-risk localized disease. Some of it may be smoking for the case of prostate cancer as well. It is a smoking-related tumor, not as obviously as bladder and kidney cancer are. There are other epidemiologic factors as well, but there's no question that a lot of this drop we can credit to screening. The mortality declines pretty much flattened out as of 2013-2014.

Now that was a little bit too soon to blame it directly on the 2012 US Task Force D recommendation. There are probably some other factors that are tending to drive prostate cancer mortality increases. Part of it is just the aging male population, less early cardiac death. There are secular trends out there, but I think we can say it was the worst possible time to stop screening. Mortality rates started ticking up a little bit. They're mostly flat for the current year, but it does seem clear that we need to get back to a smarter middle ground of screening—using screening more intelligently, finding the high-grade cancers and treating them—so that we can get that mortality curve back on a downward trajectory.

This transcript was AI generated and edited by human editors for clarity.