Long-term trends in the burden of prostate cancer in the United States from 1990 to 2021: A detailed analysis based on the Global Burden of Disease Study 2021

Abstract

Prostate cancer (PCa) is a major public health challenge in the United States. This study analyzed the long-term trends in PCa burden from 1990 to 2021 and provides projections for future trends. Data were obtained from the Global Burden of Disease 2021 database to evaluate PCa burden metrics in the United States and globally, including incidence, prevalence, mortality, and disability-adjusted life years. Temporal trends were assessed using joinpoint regression analysis, while age–period–cohort models were applied to evaluate the effects of age, period, and birth cohort. Decomposition analysis was performed to quantify the contributions of population growth, population aging, and epidemiological changes to variations in PCa burden. Future trends through 2036 were projected using a Bayesian age–period–cohort model. Relative to global estimates, the burden of PCa remained higher in the United States throughout the study period. In 2021, PCa imposed a significant burden on males in the United States, particularly among individuals aged 65 to 69. An estimated 2,671,779 prevalent cases, 297,836 incident cases, and 44,032 deaths were recorded. The age-standardized incidence rate and age-standardized prevalence rate in the United States exceeded the corresponding global estimates, reaching 108.04 and 967.87 per 100,000 population, respectively. Although age-standardized rates generally declined between 1990 and 2021, the absolute numbers of incident and prevalent cases continued to increase, indicating that an increasing number of individuals are living with PCa. Among U.S. states, Louisiana had the highest burden, whereas Hawaii had the lowest. Decomposition analysis revealed that population aging and population growth increased the burden of PCa, whereas epidemiological changes partially offset these increases. Projections suggested a gradual increase in the burden of PCa through 2036. These findings highlight the need for targeted public health strategies to reduce the future burden of PCa in the United States.

1. Introduction

Prostate cancer (PCa) is one of the most prevalent malignancies among men globally, posing a substantial public health challenge due to its high incidence and associated mortality. According to the GLOBOCAN 2022 report, PCa ranks as the 2nd most common cancer globally and is the 5th leading cause of cancer-related mortality among men, with an estimated 1,466,680 new cases and 396,792 deaths reported worldwide.^[1] The highest incidence rates are observed in North America, Australia, and Northern Europe, whereas lower incidence rates are reported in several regions of Asia and Africa. For instance, in Northern Europe, the age-standardized incidence rate (ASIR) is around 83 cases per 100,000, while in regions like South-Central Asia, the ASIR is as low as 3.1 per 100,000.^[2] Similarly, the mortality rate of PCa is significantly lower than that reported in developed regions, especially in South-Central Asia. The reasons for these lower rates may include a potentially lower susceptibility of Asian men to PCa and the absence of widespread systematic screening programs in these regions.^[3] The 5-year relative survival rate for PCa is significantly higher in high-income countries, such as the United States (approximately 98%), while it remains substantially lower in low-income regions, particularly in Sub-Saharan Africa (<20%). This phenomenon is partly attributed to the late diagnosis of PCa, which often occurs at an advanced stage where treatment options are significantly limited.^[4,5]

Several well-established risk factors are associated with the development of PCa, including age, ethnicity, family history, and lifestyle choices. Notably, the risk increases substantially after the age of 50, and the majority of cases are diagnosed in men aged 65 and older.^[6] Ethnicity plays a critical and multifaceted role in determining risk levels, with African American men exhibiting a significantly higher risk compared to Caucasian and Asian men.^[7] This disparity is often attributed to a combination of genetic predispositions and socioeconomic inequalities. Lifestyle factors, including obesity, a diet high in red meat and dairy products, and physical inactivity, have been associated with an increased risk. Additionally, hormonal factors, particularly elevated levels of androgens, are considered to contribute to the process of tumorigenesis.^[8]

In the United States, PCa continues to be a predominant cause of cancer diagnoses among men. According to data from the American Cancer Society, approximately 288,300 new cases were projected for 2023, accounting for roughly 29% of all newly diagnosed cancer cases in males. Despite its high incidence rate, mortality rates have decreased substantially over the past few decades. Nonetheless, it remains the second leading cause of cancer-related mortality in American men, with an estimated 34,700 deaths anticipated in 2023.^[9] PCa continues to be a major health concern globally and within the United States. Despite advancements in screening and treatment methodologies, substantial disparities in incidence and mortality rates continue to exist, particularly among diverse ethnic populations and across socioeconomic strata.

As a critical public health concern, understanding its epidemiology is crucial for formulating effective prevention and treatment strategies. This paper aims to present a detailed overview of the trends in PCa in the United States, utilizing data from the Global Burden of Disease (GBD) 2021 database. We conducted an in-depth study on the incidence, prevalence, mortality, and disability-adjusted life years (DALYs) of PCa in the United States through extensive analyses, including joinpoint regression analysis, age–period–cohort (APC) analysis, decomposition analysis, and Bayesian age–period–cohort (BAPC) analysis. The findings carry substantial implications for public health research, policy development, and health management, facilitating the identification of critical health challenges and prioritization of key areas.

2. Methods

2.1. Data source

Data regarding the incidence, prevalence, mortality, and DALYs of PCa in the United States and globally from 1990 to 2021 were obtained from the GBD 2021 database via an online tool (https://ghdx.healthdata.org/gbd-results-tool). The data are presented as estimates along with their corresponding 95% uncertainty intervals, including age-standardized rates and age-group-specific data. The GBD 2021 database, supported by the Institute for Health Metrics and Evaluation at the University of Washington, provides detailed data on 371 diseases and injuries, as well as 88 risk factors across 204 countries and regions. This is achieved through the application of advanced modeling tools such as DisMod-MR 2.1, the Cause of Death Ensemble modeling (CODEm) framework, and Spatio-Temporal Gaussian Process Regression.^[10,11] Based on the International Classification of Diseases (ICD), PCa is classified under codes C61 to C61.9 for the ICD-10 and 185 to 185.9, V10.46, V16.42, V76.44 for ICD-9.^[12] This study adheres to the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) guidelines to ensure precise and transparent health estimates.^[13]

2.2. Joinpoint regression analysis

In order to identify the significant changes in PCa trends over time, joinpoint regression analysis was employed with the help of Joinpoint Regression Program version 5.3.0 (National Cancer Institute, Rockville, MD). This method identifies points where a significant change in the trend of a data series occurs, calculating the APC and the average annual percent change (AAPC).^[14] Statistical significance was determined using permutation tests with a P-value threshold set at <.05. The APC and AAPC for each segment were estimated as:

$${\displaystyle \mathrm{l}\mathrm{n}\left(APC\right)=\left[\frac{y_{x+1}-y_x}{y_x}\right]*100\%=(e^{{\beta }_1}-1)*100\%}$$

where y represents the age-standardized rate, x denotes the corresponding calendar year, and β₁ is the estimated regression coefficient.

$$\begin{array}{c}{\displaystyle }\mathrm{l}\mathrm{n}\left(AAPC\right)=(e^{\sum {\omega }_i{\beta }_i/\sum {\omega }_i}-1)*100\%\end{array}$$

where ωᵢ is the width of the ith segment (in years) and βᵢ is the corresponding regression coefficient for that interval.

2.3. Age–period–cohort analysis

Age–period–cohort analysis is a statistical method used to disentangle the effects of age, period, and cohort on observed trends in diseases. To address the collinearity challenges commonly encountered in age–period–cohort models, the intrinsic estimator (i.e.) method was used, providing more accurate estimations of age, period, and cohort effects.^[15] Birth cohorts were calculated as the difference between calendar period and age group midpoint and were grouped into consecutive 5-year intervals. In 5-year intervals, the data extracted from the GBD database were divided into 16 age groups (e.g., 20–24, 25–29, etc) and 5 periods spanning from 1992–1996 to 2017–2021. Then, we employed the Epi package (version 2.59) in R-studio software (version 4.4.2) to fit the age–period–cohort model.

2.4. Decomposition analysis

Decomposition framework proposed by Das Gupta was adopted, which was used for breaking down metric datasets to gain insights into contributing factors such as aging, population expansion, and epidemiological transitions of PCa burden.^[16] We decomposed the overall change in the PCa metric to provide clearer insight into the driving forces behind the observed trends. The formula is as follows (taking DALYs as an example):

$$\begin{array}{c}{\displaystyle }DAL{Y}_{ay,py,ey}=\sum _{i=1}^{20}\left(a_{i,y}\right)\times \left(p_y\right)\times \left(e_{i,y}\right)\end{array}$$

where DALY_ay,py,ey represent the age structure, population, DALY rate, and other factors based on a specific year y; a_i,y indicates the population proportion of age group i among 20 age groups in year y; p_y represents the total population in a given year y; e_i,y represents the DALY rate for a given age category i in year y. From 1990 to 2021, each factor’s contribution to the change in DALY was defined by the effect of 1 factor changing while the others remained constant. For example, the effect of age structure was calculated as:

([DALY_{a2021, p1990, e1990} + DALY_{a2021, p2021, e2021})/3 + [DALY_{a2021, p1990, e2021} + DALY_{a2021, p2021, e1990}]/6) − ([DALY_{a1990, p2021, e2021} + DALY_{a1990, p1990, e1990}]/3 + [DALY_{a1990, p2021b, e1990} + DALY_{a1990, p1990, e2021}]/6).

2.5. BAPC analysis

BAPC analysis was used for future PCa burden projection. We fitted the model with observed data from 1990 to 2021 and projected data up to 2036. To more effectively fit the model and circumvent the need for Markov chain Monte Carlo sampling, we implemented Integrated Nested Laplace Approximation algorithms.^[17] All analyses were conducted in R-studio software (version 4.4.2) using the BAPC (version 0.0.36) and Integrated Nested Laplace Approximation (version 24.06.27) packages.

2.6. Statistical analysis

Statistical analyses were performed using the open-source R-studio software (version 4.4.2). P-values <.05 were considered to indicate statistical significance.

3. Results

In 2021, PCa imposed a significant burden on males in the United States, with a total prevalence of 2,671,779 cases. Additionally, the United States reported 297,836 new cases of PCa and 44,032 associated deaths. The ASIR, age-standardized prevalence rate (ASPR), age-standardized mortality rate (ASMR), and age-standardized DALYs rate (ASDR) in the United States all exceeded the corresponding global estimates, reaching 108.04, 967.87, 16.48, and 334.57 per 100,000 population, respectively (Table 1). Figure 1 shows the age-specific distribution of PCa incidence, prevalence, deaths, and DALYs in the United States and globally in 2021. Most PCa burden metrics increased with age, peaked among older adults, and subsequently declined in the oldest age groups. Globally, the highest incidence and prevalence of PCa were observed among individuals aged 70 to 74 years. However, the highest incidence and prevalence burden in the United States was observed among individuals aged 65 to 69 years (Fig. 1A and B). Both the United States and global estimates showed increasing ASMR and ASDR with advancing age, although the rates were generally higher in the United States (Fig. 1C and D). Additionally, a comparison of PCa burden between the United States and the global population in 1990, stratified by age group, is presented in Supplementary Figure 1, Supplemental Digital Content 1. Overall, the incidence, prevalence, mortality, and DALY rates of PCa were higher in the United States than at the global level across most age groups. In both populations, the burden of PCa increased markedly with age, with the highest rates observed among older adults. Compared with the global average, the United States exhibited a greater PCa burden in most age groups.

Table 1.

All-age cases and age-standardized rates of incidence, prevalence, deaths, and DALYs for PCa in the United States and globally in 1990 and 2021.

Locations	Measures	All-ages cases		Age-standardized rates (per 100,000)		AAPC (%)	P-value
		1990	2021	1990	2021
Global	Incidence	506,405 (480,851–524,697)	1324,383 (1217,321–1400,222)	32.64 (30.86–33.86)	34.05 (31.27–36.00)	0.15 (0.052 to 0.25)	<.01
	Prevalence	3596,220 (3445,437–3705,436)	10,387,521 (9705,680–10,904,400)	218.33 (208.48–225.67)	260.05 (243.39–272.68)	0.57 (0.47 to 0.67)	<.01
	Deaths	211,972 (194,222–224,328)	432,463 (381,873–463,645)	16.35 (15.02–17.28)	12.63 (11.16–13.55)	−0.83 (−0.51 to −0.40)	<.01
	DALYs	4146,719 (3754,315–4401,620)	8141,561 (7177,067–8809,184)	275.3 (251.66–292.14)	217.83 (192.65–235.53)	−0.75 (−0.82 to −0.68)	<.01
The United States	Incidence	186,553 (178,410–192,647)	297,836 (280,073–311,400)	135.42 (129.14–139.97)	108.04 (101.48–113.04)	−0.77 (−1.01 to −0.53)	<.01
	Prevalence	1522,355 (1465,187–1576,800)	2671,779 (2547,383–2786,354)	1100.78 (1059.29–1139.16)	967.87 (921.95–1008.71)	−0.45 (−0.66 to −0.24)	<.01
	Deaths	37,349 (35,034–38,685)	44,032 (39,406–46,728)	29.45 (27.37–30.65)	16.48 (14.66–17.51)	−1.90 (−1.26 to −0.98)	<.01
	DALYs	770,154 (725,217–816,136)	912,428 (833,911–989,999)	573.95 (539.41–607.63)	334.57 (306.05–363.08)	−1.76 (−1.90 to −1.63)	<.01

Values are presented as posterior mean estimates with 95% uncertainty intervals in parentheses.

AAPC = average annual percent change, DALYs = disability-adjusted life years, PCa = prostate cancer.

Figure 1.

Age-standardized distribution of PCa incidence, prevalence, deaths, and disability-adjusted life years (DALYs) in the United States and globally in 2021. (A) Incidence; (B) prevalence; (C) deaths; (D) DALYs. Bars represent the absolute numbers of cases, deaths, or DALYs and correspond to the left y-axis. Lines represent age-specific rates per 100,000 population and correspond to the right y-axis. Blue indicates global estimates, whereas red indicates estimates for the United States. Error bars for the bars and shaded areas around the lines represent 95% uncertainty intervals. PCa = prostate cancer.

Figure 2 illustrates the temporal trends in PCa incidence, prevalence, mortality, and DALYs in the United States and globally from 1990 to 2021. In the United States, age-standardized incidence, prevalence, mortality, and DALY rates all showed declining trends over the study period, with negative AAPC values for all measures (Table 1). Globally, ASIR and ASPR increased slightly, whereas age-standardized mortality and DALY rates declined. In contrast, the absolute numbers of incident cases, prevalent cases, deaths, and DALYs increased substantially in both the United States and globally.

Figure 2.

Temporal trends in PCa incidence, prevalence, deaths, and DALYs in the United States and globally from 1990 to 2021. (A) Incidence; (B) prevalence; (C) deaths; (D) DALYs. Bars represent the absolute numbers of cases, deaths, or DALYs and correspond to the left y-axis. Lines represent age-standardized rates per 100,000 population and correspond to the right y-axis. Blue indicates global estimates, whereas red indicates estimates for the United States. Error bars for the bars and shaded areas around the lines represent 95% uncertainty intervals. DALYs = disability-adjusted life years, PCa = prostate cancer.

Figure 3 presents the results of the joinpoint regression analysis of age-standardized PCa rates and identifies specific time points at which significant changes in trend occurred and quantifies the corresponding APCs in the United States and globally from 1990 to 2021. In the United States, ASIR and ASPR exhibited significant joinpoints around 1995, with increasing trends before 1995 followed by sustained declines thereafter. Specifically, ASIR increased by 1.73% annually from 1990 to 1995 and subsequently decreased by 1.84% annually from 1995 to 2006. Similarly, ASPR increased by 1.97% annually between 1990 and 1995 and then decreased by 1.32% annually from 1995 to 2006 (Fig. 3A and B). For global mortality and DALY rates, joinpoint regression identified brief periods of increase between 2003 and 2013 for ASMR and 2010 and 2013 for ASDR. However, the magnitude of these changes was relatively small, and the overall long-term trends remained stable or slightly declining (Fig. 3C and D).

Figure 3.

Joinpoint regression analysis of age-standardized rates for PCa in the United States (green line) and globally (blue line) from 1990 to 2021. (A) ASIR. (B) ASPR. (C) ASMR. (D) ASDR. ASDR = age-standardized disability-adjusted life years rate, ASIR = age-standardized incidence rate, ASMR = age-standardized mortality rate, ASPR = age-standardized prevalence rate, DALYs = disability-adjusted life years, PCa = prostate cancer.

State-level PCa burden in the United States is presented in Supplementary Tables 1, Supplemental Digital Content 2 and Figure 4. In 2021, Louisiana had the highest ASIR and ASPR, reaching 146.21 and 1307.99 per 100,000 population, respectively. In contrast, Hawaii had the lowest ASIR (84.51 per 100,000) and ASPR (770.01 per 100,000). Mississippi recorded the highest ASMR and ASDR, at 23.11 and 469.34 per 100,000 population, respectively, whereas Hawaii had the lowest ASMR and ASDR. State-specific AAPCs from 1990 to 2021 are shown in Figure 4 and Supplementary Table 2, Supplemental Digital Content 3. ASIR declined in most states, with the largest decrease observed in North Dakota (Fig. 4A). California was the only state showing an increase in ASIR during the study period. A similar overall pattern was observed for ASPR, although a small number of states exhibited positive AAPC values (Fig. 4B). ASMR and ASDR decreased across all states between 1990 and 2021, with the District of Columbia experiencing the greatest reductions in both measures (Fig. 4C and D).

Figure 4.

State-level average AAPC in age-standardized PCa burden metrics in the United States from 1990 to 2021. (A) ASIR; (B) ASPR; (C) ASMR; (D) ASDR. Blue shades indicate negative AAPC values (decreasing trends), whereas red shades indicate positive AAPC values (increasing trends). Darker colors represent greater magnitudes of change. State abbreviations follow USPS 2-letter codes. Full state names and corresponding abbreviations are provided in Supplementary Table S2, Supplemental Digital Content 3. Alaska (AK) and Hawaii (HI) are shown as insets in the lower-left corner of each panel. AAPC = average annual percentage change; ASDR = age-standardized DALYs rate; ASIR = age-standardized incidence rate; ASMR = age-standardized mortality rate; ASPR = age-standardized prevalence rate, DALYs = disability-adjusted life years, PCa = prostate cancer.

Age–period–cohort analyses of PCa incidence, prevalence, and DALYs are presented in Figure 5, Supplementary Figure 2, Supplemental Digital Content 4, and Supplementary Figure 3, Supplemental Digital Content 5. Incidence rates increased markedly with age, particularly after 40 years, and reached a plateau after approximately 70 years of age (Fig. 5A). Across calendar periods and birth cohorts, the overall incidence patterns were largely similar, although a modest decline in incidence was observed in recent years (Fig. 5B–D). Similar age-related patterns were observed for prevalence, with the highest prevalence rates occurring among individuals aged 70 to 80 years (Supplementary Figure 2, Supplemental Digital Content 4). In contrast, DALY rates showed a gradual decline across age groups, periods, and birth cohorts (Supplementary Figure 3, Supplemental Digital Content 5). Overall, age effects appeared more pronounced than period and cohort effects for all 3 PCa burden metrics.

Figure 5.

Age–period–cohort analysis of PCa incidence in the United States. (A) Age-specific incidence rates by calendar period. (B) Age-specific incidence rates by birth cohort. (C) Period-specific incidence rates stratified by age group. (D) Birth cohort-specific incidence rates stratified by age group. In panel A, colored lines represent different calendar periods. In panel B, colored lines represent different birth cohorts. In panels C and D, colored lines represent different age groups. Values shown beside the curves indicate the corresponding period, birth cohort, or age group. PCa = prostate cancer.

Decomposition analyses of PCa incidence, prevalence, mortality, and DALYs were presented in Figure 6 and Supplementary Table 3, Supplemental Digital Content 6. In both the United States and globally, population growth and population aging contributed positively to increases in all PCa burden metrics. Population growth was the largest contributor to increases in incidence and prevalence, whereas aging contributed substantially to increases in mortality and DALYs. In contrast, epidemiological changes had a negative contribution to most metrics, indicating that changes in age-specific disease rates partially offset the increases attributable to demographic factors. In the United States, epidemiological changes reduced incidence, prevalence, mortality, and DALYs by 42.50%, 38.67%, 387.43%, and 345.59% of the overall change, respectively. Similar patterns were observed globally, although epidemiological changes contributed positively to prevalence. These findings suggest that demographic changes remain the major drivers of the increasing PCa burden.

Figure 6.

Decomposition analysis of changes in PCa burden in the United States and globally between 1990 and 2021. The overall change in incidence, prevalence, mortality, and DALYs was decomposed into contributions from population aging, population growth, and epidemiological change (changes in age-specific rates). Positive values indicate factors contributing to an increase in disease burden, whereas negative values indicate factors contributing to a decrease. (A) Incidence. (B) Prevalence. (C) Mortality. (D) DALYs. DALYs = disability-adjusted life years, PCa = prostate cancer.

Projected trends in PCa burden in the United States from 2022 to 2036 were shown in Figure 7 and Supplementary Table 4, Supplemental Digital Content 7. The ASIR is projected to increase gradually from 114.3 per 100,000 in 2022 to 126.3 per 100,000 in 2036. Similarly, the ASPR is expected to rise modestly over the projection period. ASMR and ASDR were also projected to increase slightly, although the magnitude of change is relatively small compared with incidence and prevalence. Overall, the projections indicated a continued increase in the burden of PCa in the United States over the next decade.

Figure 7.

Projected trends in PCa burden in the United States through 2036. Historical estimates are shown before the vertical dashed line, and projected values are shown thereafter. The solid blue line represents the posterior mean estimate, and the shaded areas indicate the corresponding uncertainty intervals, with darker shading representing narrower intervals. (A) ASIR. (B) ASPR. (C) ASMR. (D) ASDR. ASDR = age-standardized DALYs rate, ASIR = age-standardized incidence rate, ASMR = age-standardized mortality rate, ASPR = age-standardized prevalence rate, DALYs = disability-adjusted life years, PCa = prostate cancer.

4. Discussion

This study evaluates the trends of PCa metrics in the United States and its individual states from 1990 to 2021 based on the GBD 2021 database, and provides key insights into the burden and distribution of the disease. The results highlight the significant burden of PCa in the United States, marked by higher ASIR and ASPR compared to the global average. Despite a steadily declining trend in incidence and prevalence since 1995, the overall impact remains substantial, with an increasing number of patients being diagnosed. Likewise, the age-standardized mortality and DALYs rates for PCa demonstrate a decreasing trend; however, the absolute number of cancer-related deaths continues to increase.

There are numerous factors contributing to the high burden and declining trends of PCa in the United States. Firstly, population growth and the rise in average life expectancy can be used as key factors to explain the substantial increase in PCa incidence.^[18] Although fertility rates are lower than the replacement level, immigration has sustained the growth of the U.S. workforce and population. The United States was projected to experience continuous population growth until the mid-21st century.^[19] PCa is a prototypical age-related disease, and aging is recognized as one of the established risk factors.^[20] It is widely recognized that the United States is a developed country experiencing gradual population aging. Currently, individuals aged 65 and above constitute approximately 13% of the United States population. According to projections by the United States Census Bureau, this proportion is expected to surpass 20% within the next 25 years.^[21] Our results show that in the United States, the age group with the highest incidence of PCa is 65 to 69 years. Severely, the elderly population not only exhibits a higher incidence of PCa, but also a greater degree of malignancy and lower survival rates.^[22] The decomposition analysis further demonstrated that population aging and population growth were major contributors to the increasing number of PCa cases.

Additionally, the high burden of PCa is largely associated with the adoption of a Western dietary pattern and the prevalence of obesity. Studies have demonstrated that elevated dietary consumption of animal fat, meat, and dairy products may be associated with an increased risk of PCa.^[8,23] Moreover, the consumption of high-calorie food is a significant contributing factor to the increasing prevalence of obesity, which is also considered a notable risk factor for PCa.^[24] According to the National Health and Nutrition Examination Survey, between 2013 and 2016, 38.9% of adults were classified as overweight or obese, while an additional 7.6% were categorized as severely obese.^[25] Continuous unhealthy lifestyles and the rising prevalence of obesity will exacerbate the burden of PCa. Not only dietary habits and obesity, but also racial and ethnic disparities contribute significantly to the high burden of PCa in the United States. African American or Black men are 1.7 times more likely to be diagnosed with PCa compared to White men and 2.1 times more likely to die from the disease. PCa incidence and mortality rates are lower among Asian/Pacific Islanders, American Indian/Alaskan Natives, and Hispanic men than among non-Hispanic White men.^[26,27]

The PCa metric showed that ASIR and ASPR increased during the early 1990s, reached a peak around 1995, and subsequently declined, which is likely to be associated with the application of prostate-specific antigen (PSA) screening. From the late 1980s to the early 1990s, the widespread adoption of PSA screening led to a significant increase in the incidence of PCa in the United States.^[28] The subsequent increases were followed by equally significant reductions within a few years, likely reflecting the depletion of prevalent cancers. The declines thereafter were largely attributed to the reduced utilization of PSA testing. PSA tests can identify cancers that progress so gradually that they would never produce symptoms during an individual’s lifetime; however, the widespread implementation of PSA screening also presents significant challenges, such as overdiagnosis and unnecessary treatments. Treating these slow-growing cancers may result in unnecessary complications, such as urinary dysfunction and sexual health issues.^[29] The United States Preventive Services Task Force issued a recommendation in 2008 against PSA screening for men aged 75 years and older, and subsequently extended this recommendation to all men in 2012.^[9] This recommendation likely contributed to subsequent declines in PCa diagnoses. However, in 2012, PSA-based screening for PCa was discontinued for all men except for surveillance purposes in those with a prior diagnosis of PCa. Consequently, by 2017, a phenomenon referred to as “reverse migration” in disease staging was observed, characterized by a decrease in the diagnosis of localized PCa and an increase in the diagnosis of locally advanced and metastatic disease.^[30] Thus, implementing targeted screening strategies may play a critical role in balancing the benefits of early detection with the necessity to avoid unwarranted interventions.

Significant regional variations in PCa metrics are observed across states within the United States, with states such as Louisiana, Georgia, the District of Columbia, and Mississippi presenting higher rates. These disparities may be attributed to variations in socioeconomic status and lifestyles, the distribution of medical resources, demographic and racial composition, and the prevalence of PSA screening. Socioeconomic status and lifestyles differ significantly across states in the United States, influencing the epidemiology of PCa.^[31] According to data from Surveillance, Epidemiology, and End Results, significant rural–urban differences are observed in the United States for PCa management, such as diagnostic efficiency and treatment methods.^[32] It is well-established that Black individuals are more susceptible to PCa compared to other racial groups.^[7,26] In the United States, the distribution of African Americans exhibits geographic disparities, with a predominant concentration in the Midwest and Northeast regions, including major urban centers such as Chicago and New York.^[33] Additionally, African American individuals have exhibited lower rates of PSA screening and surgical interventions compared to other racial groups.^[34] Complex multifactorial elements contribute to the variations in PCa metrics across states; therefore, the development of individualized policies should be grounded in the specific circumstances of each state. The disproportionate burden in the United States highlights the urgent necessity for enhanced public health interventions to tackle the persistent challenge of PCa, which continues to be one of the most severe cancers in the region.

It is important to acknowledge the limitations of our research. Firstly, the overall quality of GBD estimates is fundamentally contingent upon the accuracy of the data sources used in the modeling process. The reliability of registry data in resource-limited countries within this region, which is characterized by a dynamically changing population due to immigration and ethnic shifts, may warrant careful examination. Thus, validation of other databases or nationwide epidemiological surveys are necessary. Secondly, elderly males with PCa are more likely to experience comorbidities stemming from other complex diseases, like cardiovascular disease, which leads to an overestimate of deaths caused by PCa. Finally, the study may be subject to limitations due to the application of statistical methods. Although these methods are robust, they might not entirely account for all confounding factors or address the potential inaccuracies inherent in large epidemiological datasets.

5. Conclusion

In summary, this study underscores the significant burden of PCa in the United States and reveals pronounced geographical disparities. Age–period–cohort analysis and decomposition analysis are used to examine the influence of specific factors on the trend of PCa in the United States from 1990 to 2021. Additionally, projection analyses indicate a modest increase in the burden of PCa through 2036. These findings provide updated evidence on the temporal and geographic patterns of PCa burden in the United States and may help inform healthcare planning and resource allocation. Adopting comprehensive and region-specific prevention strategies, particularly in high-risk regions or populations, is crucial for reducing the burden of PCa.

Acknowledgments

We acknowledge the Institute for Health Metrics and Evaluation at the University of Washington, the Global Burden of Disease Collaborators, and all supporting staff for supplying the data. The interpretations and opinions expressed in this paper are solely those of the authors and do not necessarily represent the views or policies of their affiliated organizations.

Author contributions

Conceptualization: Xinji Li, Peidong Huang.

Data curation: Gaowei Guo, Longsheng Zhang.

Formal analysis: Gaowei Guo, Longsheng Zhang, Wei Zhang.

Investigation: Gaowei Guo, Wei Zhang.

Methodology: Gaowei Guo, Longsheng Zhang, Wei Zhang, Jieming Lin.

Project administration: Xinji Li, Peidong Huang.

Software: Jieming Lin, Huirong Lin.

Supervision: Peidong Huang.

Validation: Gaowei Guo, Longsheng Zhang, Wei Zhang.

Visualization: Gaowei Guo, Longsheng Zhang.

Writing – original draft: Gaowei Guo, Longsheng Zhang, Wei Zhang.

Writing – review & editing: Jieming Lin, Huirong Lin, Xinji Li, Peidong Huang.