Studies that have reported changes in incidence or improvements in prostate cancer survival often do not discriminate between indolent and non-indolent cancers, thereby affecting and obscuring true changes in disease metrics.36 Thus, by describing fatal prostate cancer incidence in the US and England, our study provides a unique evaluation of temporal trends for a clinically relevant subset of the disease in a comparison of two countries with substantially different PSA test use histories. This evidence concerns the gene KLK3 and Familial prostate cancer.