Incidence of Metastatic Prostate Cancer at Diagnosis Rises in US Interview with:

Dr. Jim C. Hu MD MPH Professor of Urology Weill Cornell Medicine

Dr. Jim Hu

Dr. Jim C. Hu MD MPH
Professor of Urology
Weill Cornell Medicine What is the background for this study? What are the main findings?

Response: The most significant finding from our population based study is that after years of decline following the introduction of PSA screening, we see a rise in the incidence of metastatic prostate cancer at diagnosis among men aged 75 years and older. This is concerning in light of recent criticisms and guidelines against PSA testing. For instance, in 2008, the US Preventative Services Task Force recommended against PSA testing in this age group, and in our study, we see the incidence of metastasis at diagnosis rising in 2012 and 2013.

This is significant because there is no cure for men with metastatic prostate cancer of their disease. The traditional argument against PSA screening is that it leads to over-diagnosis and over-treatment of prostate cancer. However, we currently do not have a better test for diagnosing prostate cancers before it has spread beyond the prostate and metastasized. Remarkably, when Ben Stiller shared his personal use of PSA testing in his mid to late 40’s and how this led to a detection of intermediate risk prostate cancer that led him to surgery and cure, others criticized him for sharing his story. What should readers take away from your report?

Response: We in the US are doing a better job of educating and informing men that not all prostate cancers need to be treated. Several studies earlier this year demonstrated that the use of active surveillance, or just monitoring, has increased to roughly 50% of diagnosed prostate cancers. Therefore the argument that a diagnosis of cancers compels men to be treated is no longer universally the case. Men with more aggressive cancers seek treatment in hopes of preventing metastases.

Although PSA is not a perfect test, I believe like any test, the most important take away is what course and decision results from the test. For a man with an elevated PSA, the answer is no longer going straight to biopsy. Many tests based on improved imaging and precision medicine allow men to gain individualized risks for the likelihood of aggressive cancer before deciding to move forth with biopsy. Similarly, precision medicine tests allow men to better assess their risks of prostate cancer spread and death from prostate cancer before deciding whether to seek surgery or radiation, which may have side effects. What recommendations do you have for future research as a result of this study?

Response: Therefore theses medical advances as well as the improved understanding by men and physicians alike regarding the non-uniform behavior of prostate cancer has significantly shifted away from the traditional criticisms of PSA testing. However, questions remain regarding when to start using PSA testing, how frequently to undergo screening and ultimately when to stop. These are individualized decisions that men must come to grips with in contrast to the wide-sweeping, broad unconditional recommendation against PSA screening, which was made in men aged 75 years and older in 2008 and against PSA testing for all men in 2012.

Finally, these recommendations by the USPSTF was made with a flawed understanding of the randomized trial, PLCO, which had significant limitations that did not come to light when it was published in 2009 that use of PSA testing did not reduce deaths from prostate cancers in the US. In contrast, a large European study found the opposite, that PSA screening was associated with a lower risk of dying from prostate cancer. Is there anything else you would like to add?

Response: I am on the Speakers Bureau for Genomic Health. Thank you for your contribution to the community.


Hu JC, Nguyen P, Mao J, Halpern J, Shoag J, Wright JD, Sedrakyan A. Increase in Prostate Cancer Distant Metastases at Diagnosis in the United States. JAMA Oncol. Published online December 29, 2016. doi:10.1001/jamaoncol.2016.5465

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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  • Sylvia Wassertheil-Smoller
    Posted at 19:30h, 08 January

    I disagree that the only ay to show usefulness of PSA is through over-all survival On the contrary, the it is disease specific survival that is the important metric (though overall survival should also be reported). Since the most common causeof death is cardiovascular disease, and prostate cancer deaths make up a small proportion of all deaths, overall survival figures may be swamped by the CVD deaths and be barely budged by a reduction in prostate cancer deaths. For a man with prostate cancer, the most relevant question is will he die from prostate cancer? The European trial clearly proved PSA helps and the PLCO had such a high cross-over rate that its results are meaningless.

  • Chris O'Neill
    Posted at 13:49h, 04 January

    “The traditional argument against PSA screening is that it leads to over-diagnosis and over-treatment of prostate cancer.”

    Actually, the argument against PSA screening is that it leads to over-diagnosis and over-treatment of prostate cancer WITHOUT any net saving of lives.

    The only way to show PSA screening is worth doing is by demonstrating an improvement in overall survival (an improvement in disease-specific survival is not sufficient) compared with usual care and this has never been done.