Prostate Cancer Screening and Men Over 75

You may have read in the news the latest prostate cancer screening recommendation issued by the United States Preventive Services Task Force (USPSTF). This federal advisory panel also called for comments regarding its recommendation that, “For men age 75 years or older and for those whose life expectancy is 10 years or fewer, the incremental benefit from treatment of prostate cancer detected by screening is small to none.”

This advice is not new. The same recommendation was made three years ago. The rationale for their present recommendation is based on an evaluation of the most recent medical evidence which shows, the panel concluded, that the potential harms of PSA screening tests in this age group outweigh the potential benefits.

Potential benefits of PSA screening

There is no doubt that early detection of prostate cancer through a positive PSA test allows early treatment that can prevent spread and death from prostate cancer. However, most clinical trials have shown that the identification of additional prostate cancers by PSA screening is not associated with a statistically significant effect on the deaths caused by prostate cancer.

Potential harms of PSA testing

A report from your doctor that your PSA test is elevated certainly leads to psychological stress and the need to decide what to do next. Many men are willing to accept their doctor’s advice to pursue a course of “watchful waiting” to follow the progress of subsequent PSA tests. However, many men are uneasy with such uncertainty and they, as well as many doctors, prefer moving on to the next step--  a prostate biopsy--even though two-thirds of men with a positive PSA do not have prostate cancer. An additional problem is that a prostate biopsy is uncomfortable and may lead to an infection in a small number of men.

In the worst case scenario, a positive biopsy often leads to either surgery or radiation treatment. Unfortunately, this occurs even in three quarters of the men with low risk, localized cancers that would not have caused symptoms or death during the patient’s lifetime.

The mortality from a prostatectomy operation itself is small, less than 0.5 percent in young men, but older men are more likely to be at greater risk because they may already have some cardiovascular disease. In men of all ages, loss of urinary control (incontinence) and erectile dysfunction are frequent adverse effects following prostatectomy. Radiation treatment can also cause erectile dysfunction. Incontinence is unlikely, but bowel function may be abnormal for some months. 

For men younger than 75

The panel concluded that for men younger than 75 the evidence is “inadequate to determine whether screening improves health outcomes.”  Therefore, a decision needs to be made in each individual situation–so talk with your doctor.  

In view of the possible downstream consequences of a positive PSA test, physicians should probably describe the implications of the test to their patients and get informed patient consent before ordering a PSA test.

Outcry against the recommendations

As can be expected, strong objections were immediately raised against these USPSTF recommendations, just as was the case with their recommendation two years ago not to carry out routine mammograms in women in their 40s. Many urologists reacted with anger and the American Urological Association issued a statement saying that the recommendation “will ultimately do more harm than good.”  One hopes that these objections are based purely on the best interests of their patients, but it is hard to ignore the fact that much of urology is dedicated to the highly profitable business of prostate biopsies and surgery.  

How else can we control the cost of medical care?

I would also like to point out that unnecessary tests and procedures are one reason for the unaffordable escalation in medical costs. The only possible way to decide which tests and procedures are worthwhile is to examine closely the available medical evidence. And then physicians and patients alike must pay heed to recommendations based on such medical evidence.

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