An epidemiological overview of prostate cancer trends in Taiwan

Dear Editor, Prostate cancer (PCa) ranks fifth in incidence and sixth in mortality among male cancers in Taiwan1. According to national data (Health Promotion Administration, Ministry of Health and Welfare, Taiwan) (Fig. 1), the age-standardized incidence rate rose from approximately 23 per 100,000 in 2006 to over 35 per 100,000 in 2021, while mortality remained stable between 5 and 8 (Fig. 1A, B). Most cases are invasive and occur in men over the age of 60 (Fig. 1C, D). Between 2007 and 2017, poorly differentiated tumors were most common, and from 2018 to 2021, Grade group 5 cases predominated (Fig. 1E, F), indicating that PCa is often diagnosed at a high grade.Figure 1.: Trends in prostate cancer in Taiwan (1980–2021): (A) age-standardized rate of incidence and mortality (2006–2021); (B) trends in prostate cancer incidence in Taiwan (1980–2021); (C) number of in situ cases by primary site and age group (2007–2021); (D) number of cases by primary site and age group (2007–2021); (E) histological differentiation trends (2007–2017); (F) American Joint Committee on Cancer grade group distribution (2018–2021).It is well established in clinical practice that average prostate-specific antigen (PSA) levels increase as men age, largely due to the natural enlargement of the prostate gland. To account for this physiological change, the implementation of age-specific PSA reference ranges is widely supported. The suggested cutoff values were 2.5 ng/mL for men aged 40 to 49, 3.5 ng/mL for ages 50 to 59, 4.5 ng/mL for ages 60 to 69, and 6.5 ng/mL for men aged ≥70. This approach laid the foundation for early “age-adapted” PSA cutoff values. Unlike Western countries, where PSA screening began in the 1980s2, Taiwan does not implement broad screening, which may contribute to the continued rise in incidence3. Taiwan’s mortality remains steady, which aligns with patterns observed in other countries2. Risk factors include age, race, family history, and diet3. In older adults, cancer aggressiveness and Gleason scores are strongly correlated with mortality, ranging from 10% for Gleason <6 to over 60% for Gleason ≥84. From 2018 to 2021, 40% of new PCa cases in Taiwan were grade groups 4 to 5. In 2021, only 9.84% of cases were stage I, while stage IV accounted for 33.47% (Health Promotion Administration, Ministry of Health and Welfare, Taiwan). This pattern underscores the urgency of developing more effective, risk-adapted screening protocols to enable earl20er detection and reduce the burden of advanced-stage disease. PSA’s limited specificity has led many countries to abandon universal screening3. A 2019 study reported that among Asian men with PSA levels of 4.0 to 10.0 ng/mL, the cancer detection rate was 13.1%, with only 8.1% being high grade5. Given the dated nature of these reference ranges and the evolving understanding of PCa biology, the focus should now shift toward enhancing the detection of clinically significant PCa—either through refined biomarkers such as p2PSA or the integration of multiparametric magnetic resonance imaging—to improve diagnostic accuracy and ultimately reduce PCa-related mortality. As to Taiwan, PSA tests are typically ordered for symptomatic patients or as self-paid items. Biopsies are reimbursed when PSA exceeds 4.0 ng/mL or if rectal exam findings are suspicious, and additional prebiopsy evaluations, such as multiparametric magnetic resonance imaging or prostate health index, may be used1. Moreover, to improve accuracy, National Health Insurance began covering p2PSA testing in December 2024, targeting patients in the PSA gray zone or with a family history of PCa. Whether this policy reduces unnecessary biopsies and improves outcomes requires further evaluation. Notably, the average age at diagnosis declined from 75 in 2007 to 72 in 2021, which requires further investigation. These findings underscore the need for refined, risk-based screening strategies tailored to Taiwan’s population.