Page 18 - An Evidence Review of Active Surveillance in Men With Localized Prostate Cancer

we considered generating forest plots for comparative effectiveness data for Key Question 4, the
data were inadequate for forest plots to be informative (i.e., there were generally only one or two
studies addressing a specific question).

Grading the Body of Evidence
We graded the body of evidence only for the comparative effectiveness review portion of the
systematic review (i.e., Key Question 4). We used standard AHRQ EPC methodology. We
assessed the risk of bias of the studies based on their study design and methodological quality,
the consistency of data across studies, the applicability of the studies to the U.S. population of
men with localized prostate cancer, potential problems with measurement of outcomes in studies,
and the precision and sparseness of data. The strength of evidence was rated on a four-level
scale: High, Moderate, Low, and Insufficient. Ratings were assigned based on our level of
confidence that the evidence reflected the true effect for the major comparisons of interest.

Results

Key Question 1. How have the patient population and the natural history of
prostate cancer diagnosed in the United States changed in the last 30
years?

We identified 79 relevant primary observational studies and one systematic review. Of the
primary observational studies, 51 analyzed the SEER database or a subset of its component
registries, 9 the linked SEER-Medicare database, 11 the Cancer of the Prostate Urologic
Research Endeavor (CaPSURE) database, 5 the National Cancer Database (NCDB), and 3
examined other large U.S.-based databases. In addition, we queried the online SEER database
and reviewed the latest version of the Cancer Statistics report prepared annually by the American
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Cancer Society, and a recent SEER Survival Monograph.
Trends in Prostate Cancer Incidence

Prostate cancer incidence rates rose between 1975 and 1992 (from approximately 100 to
more than 240 new cases per 100,000 men per year), and then fell until around 1995. After a
period of nonsignificant increase from 1995 to 2000, rates declined again from 2000 to 2007 (to
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the current level of approximately 156 new cases per 100,000 men per year). Overall, 33 studies
provided information on trends of prostate cancer incidence stratified by factors relevant to Key
Question 1.

Age
Eleven studies (covering 1969-2005) reported prostate cancer incidence rates according to
age group. Collectively, they indicated an increase within all age groups until 1992-93 and then a
decline until 1995-99. One study reported the following: compared to the pre-PSA era (1986),
the incidence rates in 2005 were 3.64 times higher for men aged 50-59 years, 1.91 times higher
for men aged 60-69, and 1.09 times higher for men aged 70–79 years, but only 0.56 times as
common in men 80 years or older.

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