PSA Testing in Older Men

Last Modified: July 22, 2010

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Question

My PSA test results have been 0.3-0.4ng/ml since testing started at age 55. Until age 70 PSA tests were every 5 years. Starting with age 70 my physician has done PSA tests every year with the same results. I am 75 andf when I ask why the increased testing, the answer was "This is an excepted standard, since there is a higher incident of Protate Cancer in older men." I am having trouble verifying the need for the increased testing and the real benefits vs. the cost.

Answer

Neha Vapiwala , MD, Senior Editor of OncoLink and Chief Resident in the Department of Radiation Oncology at the Hospital of the University of Pennsylvania, responds:

Guidelines

PSA screening is commonly recommended for men over age 50 and potentially earlier if there are associated risk factors (i.e. family history, race/ethnicity). The American Cancer Society and the National Cancer Comprehensive Network recommend offering screening to patients over 50 years with a life expectancy of at least 10 years. Earlier screening is suggested for African American men and men with family history of prostate cancer diagnosed under the age of 65. Other society recommendations vary slightly. For instance, the American Urological Association recommends a baseline PSA and digital rectal exam starting at age 40. In contrast, the US Preventive Services Task Force (an organization that makes recommendations about preventive care services for patients) maintains that there is insufficient evidence to assess the balance of the benefits and harms of screening.

Implications of increased PSA screening Prostate cancer is a disease of older men, and 64% of new cases are diagnosed in men over the age of sixty-five.1 PSA screening frequency increases in older men in order to address this factor. Secondly, older patients are more likely to have other illnesses and thus a greater utilization of health care, including doctors' visits. There is literature to suggest that increased screening among older men is not due to guideline recommendations but rather inefficiencies in practice patterns.2-3

The US Preventive Services Task Force recommends against screening in men 75 years an older, indicating that there is inadequate benefit in terms of improved health outcomes.4 Older men with well- to moderately-differentiated cancer are more likely to die of other competing causes of death than they are to die of their prostate cancer.5 The risks of the overuse of PSA screening include increasing the number of false positives and the harm of potential overtreatment in men with low risk prostate cancer. The increase in PSA testing has created a "lead-time" bias in the diagnosis of prostate cancer, meaning prostate cancers are detected at earlier stages than in the past. The economic implications of overtreatment in low-risk prostate cancer are real; anywhere from 50-100 low-risk patients might need to be treated in order to prevent 1 patient from dying of prostate cancer.6-7 Thus, many men with early stage, low-risk prostate cancer are more likely to live with their prostate cancer than to die of their prostate cancer.

Conclusion

In keeping with recommendations by all the above medical societies, PSA screening is a decision that should be discussed between the patient and physician in order to appropriately address the potential benefits and harms for the individual patient.

  1. Heinzer, H., Steuber, T.: Prostate cancer in the elderly. Urol Oncol, 27: 668, 2009
  2. Vogeli, C., Shields, A. E., Lee, T. A. et al.: Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med, 22 Suppl 3: 391, 2007
  3. Richter, F., Dudley, A. W., Jr., Irwin, R. J., Jr. et al.: Are we ordering too many PSA tests? Prostate cancer diagnosis and PSA screening patterns for a single Veterans Affairs Medical Center. J Cancer Educ, 16: 38, 2001
  4. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med, 149: 185, 2008
  5. Lu-Yao, G. L., Albertsen, P. C., Moore, D. F. et al.: Outcomes of localized prostate cancer following conservative management. JAMA, 302: 1202, 2009
  6. Klotz, L.: Active surveillance with selective delayed intervention for favorable risk prostate cancer. Urol Oncol, 24: 46, 2006
  7. Schroder, F. H., Hugosson, J., Roobol, M. J. et al.: Screening and prostate-cancer mortality in a randomized European study. N Engl J Med, 360: 1320, 2009


News
Benefit of PSA Reduced by Loss of Quality-Adjusted Life-Years

Aug 16, 2012 - Although the European Randomized Study of Screening for Prostate Cancer has reported a 29 percent reduction in prostate-cancer mortality for men who undergo prostate-specific antigen screening, the benefit is attenuated by loss of quality-adjusted life-years due to post-diagnosis effects, according to a study published in the Aug. 16 issue of the New England Journal of Medicine.



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