Diabetes, prostate cancer screening and risk of low- and high-grade prostate cancer: an 11 year historical population follow-up study of more than 1 million men

Abstract

Aims/hypothesis: An inverse association has consistently been shown between diabetes and prostate cancer incidence. We investigated whether lower prostate cancer incidence among men with diabetes is attributable to lower detection due to prostate cancer screening patterns.

Methods: We studied a population-based historical cohort of 1,034,074 Israeli men aged 21-90 years, without a previous history of cancer. The cohort was followed-up from 2002 to 2012, according to diabetes morbidity, for frequency of prostate-specific antigen (PSA) testing, mean PSA values and detection of prostate cancer, after adjustment for age, ethnic origin, socioeconomic status and PSA testing.

Results: In January 2002, 74,756 men had prevalent diabetes. During the 11 year follow-up, 765,483 (74%) remained diabetes-free and 193,835 developed diabetes. Approximately 10% more PSA screening was performed in men with than without diabetes, but the rate of PSA positivity (>4 μg/l) was 20% lower in men with diabetes. PSA values were already significantly lower in men who developed diabetes than in those who did not, 3 years before diabetes diagnosis. Reduced prostate cancer risk was observed among men with incident diabetes only for low-moderate grade tumours (Gleason score 2-6: adjusted HR 0.83; 95% CI 0.77, 0.89). No association was observed for high-grade tumours (Gleason score 7-10: HR 0.99; 95% CI 0.88, 1.11).

Conclusions/interpretation: Our findings suggest that diabetes comorbidity is a factor to be considered in prostate cancer screening strategies, and specifically in the interpretation of PSA levels. Furthermore, our demonstration of reduced incidence of low-moderate grade but not high-grade prostate cancer tumours among men with diabetes supports the possibility that low PSA levels, rather than lower tumour risk, explains the observed reduced incidence of prostate cancer in men with diabetes.

Trial registration: ClinicalTrials.gov NCT02072902.

Keywords: Diabetes; Ethnic origin; Gleason score; PSA screening; PSA testing; Prostate cancer; Socioeconomic status.

Figures

Fig. 1

Percentage of PSA testing and 95% CI in 2008 in men with diabetes aged ≥50 years, according to year of diabetes incidence, adjusted for age, SES and ethnic group. The dashed line shows the 30.6% figure for PSA screening in 2008 for men not diagnosed with diabetes during the study period

Fig. 2

Geometric mean PSA levels by calendar year for men aged 50–70 years in 2008, who were diagnosed with diabetes in the year 2008 (solid line) and men free of diabetes at the end of 2008 (dashed line), adjusted to data for a 60-year-old man. The number of observations in each year is shown below the graph; NS, not significant; p > 0.05; **p < 0.01; ***p < 0.001

Fig. 3

Geometric mean PSA levels by calendar year for men aged 50–70 years in 2002 who were tested for PSA, according to diabetes status in 2002, adjusted to data for a 60-year-old man. Solid line, diabetic men diagnosed before 2002, dashed line, diabetic men diagnosed in 2002; dotted line, men not diagnosed with diabetes during 2002–2012. The number of observations in each year is shown below the graph. The curves of the diabetic groups are significantly different from the curve of the non-diabetic group at each time point (p < 0.001). Dx, diagnosis