December 14, 2006

In this Issue...

Going Against the Guidelines: High Rates of PSA Screening Persist Among Elderly Men

by Julie McDowell


The American Cancer Society (ACS) and the American Urological Association (AUA) recommend that men over the age of 50 with an average risk for developing prostate cancer undergo an annual prostate-specific antigen screening (PSA) only if they have more than a 10-year life expectancy. However, PSA screening rates continue to be high, especially among men in their 70s and 80s who have diseases that will likely limit their life expectancy, according to a recent study in the Journal of the American Medical Association (JAMA). This issue of Strategies analyzes these recent findings and looks at the concerns associated with screening elderly men with limited life expectancies.

Even though current guidelines on PSA testing from most medical associations—including ACS, AUA, as well as the U.S. Department of Veterans Affairs (DVA)—recommend screening men over 50 if they have a life expectancy over 10 years, Louise Walter, MD, from San Francisco’s VA Medical Center was alarmed at the large number of her elderly patients who were being tested, even though their life expectancy was questionable because of their other diseases. Patients were confused and anxious about the test results, and in some cases went on to have biopsies.

“One of the harms of doing PSA tests in this population is that if there are results with elevated levels, it definitely makes people anxious and for many of my patients, it is distracting to the care that we are giving them for other diseases,” said Walter, who is also Associate Professor of Geriatric Medicine at the University of California, San Francisco. “Another issue for older men, more so than younger men is that you are more likely to have a false-positive result. It’s a less accurate test in older men because their prostate gets bigger, and therefore elevated results are more likely because the patient has a big prostate, not because he has prostate cancer.”

In order to assess how the screening rates compared to the guidelines, Walter and her colleagues analyzed data on almost 600,000 male veterans age 70 years and older who were seen at 104 DVA facilities during 2002 and 2003. These men did not have a history of prostate cancer, elevated PSA results, or prostate cancer symptoms. Based on DVA and Medicare claims data, the study’s results published in the Nov. 15, 2006 issue of JAMA showed that 56% of elderly men over the age of 70 had a PSA performed (JAMA 2006;296:2336–2342, http://jama.ama-assn.org/cgi/content/short/296/19/2336). The results also showed that while PSA screening rates did decrease with age, the rates did not significantly decrease within some age groups, despite worsening health. For example, the study found that among men age 85 years and older, there was little difference in screening rates between men in the best health (34%) and the worst health (36%). In fact, screening rates exceeded 60% for some groups of men in the worst health.

Concerns about Acting on PSA Results

In addition to concerns about anxiety among elderly patients who undergo PSA testing, Walter is also worried that too many patients are acting on the results. In cases where a patient has low-grade prostate cancer, sometimes the treatment can have a negative impact on his health. “Even though my patients are told not to worry about their PSA levels, that’s all they worry about in some instances,” she explained. “Then they might get radiation or some other type of procedure to take care of the cancer, but this treatment might leave them with incontinence, impotence, or a variety of other conditions. In elderly patients who have some other severe medical illnesses, we know that prostate cancer would not have impacted them as much as their other illnesses.”

One way to lower screening rates among elderly men is for clinicians to discuss the pros and cons of PSA testing with these patients, so that they fully understand the complications of both the test and results. However, this is not realistic for many doctors because of the time involved in having this discussion with patients and answering their questions. In the laboratory, clinical lab directors should not hesitate to point out these guidelines to clinicians, particularly those who are ordering a significant number for elderly patients with other medical issues, if the laboratory director has access to the patients’ ages, said Walter.

However, it’s important to keep in mind that there are many reasons that elderly patients get PSA tests; many ask for the test, seeing it as a preventive measure, even though the risk is miniscule, explained Peter C. Albertsen, MD, MS, Division Chief and Program Director, Division of Urology at the University of Connecticut Health Center in Farmington, who wrote an editorial accompanying Walter’s study in JAMA. “The question is, are we actually doing good, in the sense of lowering prostate cancer mortality rates? This is still open to debate,” he added. “The PSA is such an exquisitely sensitive test and because we have this huge pool of indolent cancer, we are grossly overdiagnosing prostate cancer in this country. We are also selling the fear of cancer, which in turn is driving a whole industry that sells surgery, radiation, and moving lots of money through our health care system to cure something that may or may not need to be cured, all because this PSA test is so sensitive.”

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