Many Older Men Still Tested for PSA, Contrary to Guidelines

Zosia Chustecka

April 25, 2012

April 25, 2012 — New data from a national health survey in the United States show that the guidelines for prostate cancer screening are being ignored. Many men 75 years and older are still undergoing prostate-specific antigen (PSA) testing, despite recommendations against this practice.

These data are reported in a research letter published in the April 25 issue of JAMA.

The US Preventative Services Task Force (USPSTF) issued a grade D recommendation against PSA screening in men 75 years or older in 2008.

However, the new data show that 43.9% of men in this age group were screened in 2010, and that there has been no decrease since 2005.

"PSA screening for more than 40% of men 75 years or older is inappropriate," senior author Scott Eggener, MD, assistant professor of surgery at the University of Chicago Medical Center in Illinois, said in a statement.

"Our data are likely an underestimate," he added.

Men in this age group are more likely to die from something else before a prostate cancer interferes with the quality and duration of their life, Dr. Eggener explained in the statement.

"Selective screening is reasonable to consider for the healthiest of men over age 75, but for the majority of men in this age group, early detection can lead to treatment of a disease that will probably never cause a problem," he said.

Media Headlines

The inappropriateness of screening older men was a hot topic in the media last week, in reaction to the news that high-profile businessman Warren Buffet was diagnosed with prostate cancer — at age 81 — after a PSA test and biopsy.

Among the many comments posted on Twitter, Benjamin Davies, MD, professor of urology at the University of Pittsburgh and chief of urology at Shadyside Hospital, UPMC, in Pennsylvania, wrote: "If one of my residents biopsied an 81 year old (with no mets), I would fire them on the spot." Later, he said this comment was made "tongue in cheek," and added that he does screen some healthy men, but "once you know the diagnosis, it's hard not to treat."

"I would agree with that," said lead author Sandip Prasad, MD, MPhil, from the University of Chicago Medical Center.

The overwhelming majority of men who are diagnosed with prostate cancer in the United States have some form of treatment, he told Medscape Medical News in an interview. Although significantly more men are undergoing active surveillance in recent years, it is still a minority, which he estimated to be around 10% to 20%.

Similar sentiments have been voiced by many experts discussing PSA screening and active surveillance as a management option, instead of treatment, especially for early-stage prostate cancer in older men. These issues are now getting an airing in the media, with the Buffet case being used to illustrate the points.

Buffet, chief executive officer of Berkshire Hathaway, disclosed the details of his prostate cancer in an open letter to shareholders. "I discovered the cancer because my PSA level recently jumped beyond its normal elevation, and a biopsy seemed warranted," he wrote. The diagnosis was stage I prostate cancer, and further CAT, MRI, and bone scans showed no metastatic spread. He is scheduled to receive radiotherapy daily for 2 months.

Some experts expressed surprise at both the regular PSA screening and the decision to opt for radiotherapy instead of active surveillance, although commentators have emphasized that they are speculating because only the physicians treating Buffet have access to the full facts of the case.

Survey Details

The new data on screening come from the National Health Interview Survey Cancer Control Supplements, which gathers information from in-person interviews each year from around 87,500 people in the United States.

Dr. Prasad and colleagues focused on men older than 40 years who had visited their physician in the previous year and who did not have any prostate-related conditions. They identified 5332 men in 2005 and 4640 in 2010, and looked at how many men in each age group had a PSA test as part of a routine examination.

The 2010 data show that routine PSA tests were undertaken in 12.5% of men 40 to 49 years of age, in 33.2% of men 50 to 59 years of age, in 51.2% of men 60 to 74 years of age, and in 43.9% of men older than 75 years.

The percentages for 2005 were very similar, indicating that the 2008 USPSTF recommendations against screening older men had little impact.

"We were surprised that there was no change," Dr. Prasad told Medscape Medical News. The 2008 recommendations were widely reported in both the lay and medical press, and "we anticipated that there would be some decline."

"Screening some older men does make sense," he said. "Those who are healthy and active and who are expected to live for some time may benefit from screening." He noted that both the American Urology Association and the American Cancer Society recommend using a 10-year life expectancy measure instead of focusing on the actual age of the patient.

The median life expectancy of a 75-year-old man in the United States is about 10 years, which means about half of men this age would be expected to live this long, he said. When considered against this 50% estimate, the finding that 43.9% of men older than 75 years underwent a routine PSA test is not so bad, but only if it is truly the healthiest 75-year-olds who are being screened, and not the 75-year-olds who are regularly visiting their doctors and who might very well be the sickest, he said.

"We don't know that," he said, adding that this is part of the group's future research.

A lot of the PSA testing is carried out in primary care. It seems that practitioners are continuing with their practices despite guidelines and recommendations, he added. However, a previous study suggested that there has been a decrease in PSA testing in men younger than 74 years.

There is some decrease in confidence in the PSA test, Dr. Prasad acknowledged.

The latest recommendation by the USPSTF, which is still being finalized, argues against all routine PSA testing in healthy men. "But for the time being, it is still the best test we have," he added.

"I would say that the majority of urologists believe that PSA screening reduces death from prostate cancer...but the issues of overdiagnosis and overtreatment go hand in hand with that," he said.

JAMA. 2012;307:1692-1694. Abstract


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