Prostate cancer trends in Canada: rising incidence or increased detection?

OBJECTIVES: To analyse trends in the incidence and mortality rates of prostate cancer in Canada according to age distribution, temporal pattern and provincial variation; to determine any association with the rate of prostatectomy; and to determine whether any observed increase in the rate of prostate cancer was due to an increase in the detection rate.
DESIGN: Descriptive epidemiologic study based on Canadian population data from 1959 to 1989 and chart review from one Canadian hospital.
SETTING: The chart review was conducted at the Ottawa Civic Hospital.
SUBJECTS: The data on prostate cancer trends were obtained from the Canadian population. Charts were reviewed for two groups of patients: (a) men discharged from inpatient care during 1976 and 1986-87 with prostate cancer first diagnosed in the same year and (b) men who underwent transurethral resection of the prostate (TURP) during 1976 and 1986. OUTCOME MEASURES: Incidence and mortality rates of prostate cancer, rates of prostatectomy and TURP, and correlations between them. From the hospital data, changes between 1976 and 1986-87 in distribution of cancer stages, distribution of cases detected incidentally after surgery for suspected benign prostatic hypertrophy and average number of slides analysed per gram of tissue obtained from prostatectomy.
RESULTS: The epidemiologic data showed that the age-adjusted incidence rates increased by 72% overall, an increase seen in all age groups over 60 years. The mortality rates increased by 29% overall, primarily in men over 85 years old. The prostatectomy rate increased by 55%. There were significant linear correlations between the national and provincial incidence rates of prostate cancer and the TURP rates. The chart review revealed that during 1976, 53% of the cases of prostate cancer diagnosed were localized, as compared with 75% in 1986-87 (p < 0.01). The proportion of tumours diagnosed incidentally in men undergoing TURP increased by 11%, whereas the number of procedures did not increase. Significantly more slides per gram of tissue were analysed in 1986-87 than in 1976 (p < 0.01).
CONCLUSIONS: The correlations between the incidence rates of prostate cancer and those of TURP suggest that increased treatment of benign prostatic disease has led to increased detection of prostate cancer. Extrapolation of the data obtained from the chart review indicates that the increase in observed incidence rates can be attributed to an increase in the rate of localized disease and thus primarily to early detection rather than to elevated risk. However, because the rate of death from prostate cancer was elevated in elderly men, increases in exposure to unestablished risk factors cannot be ruled out.