Many elderly men undergo unnecessary PSA screenings
And many younger men, who could benefit, do not
March 28, 2011
Many elderly men may undergo unnecessary prostate cancer screenings while men in their early fifties, who are more likely to benefit from early diagnosis and treatment, do not, according to a new study published March 28 in the Journal of Clinical Oncology.
Surveys conducted in 2000 and 2005 show that nearly half of men in their seventies underwent PSA screening, a blood test that can detect early signs of prostate cancer, in the past year. This is almost double the screening rate of men in their fifties. Because prostate cancer tends to grow slowly, many men in their seventies and older will die of other causes before prostate cancer requires medical attention.
The new findings--by researchers from the University of Chicago Medical Center, Harvard University and Beth Israel Hospital in Boston--underscore a long-standing concern that overuse of PSA screening may lead to unnecessary treatment, which can cause complications such as incontinence, impotence or bowel dysfunction.
"Our findings show a high rate of elderly and sometimes ill men being inappropriately screened for prostate cancer," said senior author Scott Eggener, MD, assistant professor of surgery at the University of Chicago. "We're concerned these screenings may prompt cancer treatment among elderly men that ultimately has a very low likelihood of benefiting the patient and paradoxically can cause more harm than good."
"We were also surprised to find that nearly three-quarters of men in their fifties were not screened within the past year," he added. "These results emphasize the need for greater physician interaction and conversation about the merits and limitations of prostate cancer screening for men of all ages."
While declines in prostate cancer metastases and death rates in the last 20 years coincide with widespread use of PSA-based screening, questions remain about its use. Recent studies provide conflicting evidence on whether routine PSA screening in the general population of men actually reduces the risk of dying from prostate cancer.
Based on these concerns, major organizations such as the American Cancer Society now encourage men who expect to live at least 10 years to talk with their doctor about the risks and benefits of screening, starting at age 50 for men with an average risk or at age 45 for men with higher risk.
In this study, the researchers examined results from health surveys of randomly selected households conducted in 2000 and 2005 as part of the federal government-sponsored National Health Interview Survey. The investigators calculated the estimated five-year life expectancy of each man over 40 who had received a PSA test.
They found that PSA screening rate was 24.0 percent in men ages 50 to 54. It increased with age until a peak of 45.5 percent in men ages 70 to 74. Screening rates then declined with age, with 24.6 percent of men 85 or older reporting being screened.
Among men who were 70 or older, the investigators did find that PSA screening was more common in men with a greater estimated five-year life expectancy. Approximately 47.3 percent of men who were unlikely to die in five years (an estimated chance of 15 percent or less) were screened, 39.2 percent of men with an intermediate chance (16 to 48 percent probability) of dying received screening, and 30.7 percent of those with the highest probability of death (48 percent or greater) in five years were screened.
Screening rates may reflect how frequently men visit primary care physicians, Eggener suggested. Older men tend to have more health problems that require doctor visits. This may result in more frequent PSA testing.
Physicians should be more selective in recommending PSA testing for older men, particularly those with a limited life expectancy, the authors suggest, and they should consider more routinely screening younger healthier men who are most likely to benefit from early prostate cancer diagnosis and treatment. Men are encouraged to talk with their doctor about their individual risk for prostate cancer, and about the risks and benefits of prostate cancer screening.
"Excessive screening for prostate cancer in elderly men who have limited life expectancies in the United States results in unnecessary anxiety, diagnoses, overtreatment, treatment-related morbidity, and health care expenditures without meaningful clinical benefit," the authors conclude. The note that about "three quarters of a million men with an estimated life expectancy of approximately 5 years received PSA screening in the year prior. These men are unlikely to reap a meaningful benefit."
"The overuse of PSA testing, and as a result, the often unnecessary overtreatment of men with indolent prostate cancer that will most likely never bother them, remains a huge concern for oncologists, said Nicholas Vogelzang, MD, ASCO Cancer Communications Committee member and prostate cancer specialist. "This study reinforces the notion that accurately determining life expectancy, taking into consideration a variety of factors, including age and co-existing medical conditions, is often critical to deciding on appropriate screening and subsequent treatment of elderly men with prostate cancer."
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