Before the U.S. Preventive Services Task Force Panel’s 2012 recommendation against broad PSA screening, the blood test was commonly offered to men age 50 and over (45 if you had known risk factors). The Panel’s directive started a push in the opposite direction, encouraging doctors to discuss with each patient the merits and downsides of PSA testing. This was not popular with prostate cancer support groups and with most urologists who worried about missing a window for early detection. The Panel, however, was rightly concerned that the nonspecific nature of the blood test triggered unnecessary biopsies, leading to the overtreatment of indolent prostate cancer (PCa). Because of it, hundreds of thousands of men who might have been able to go on active surveillance were stuck with side effects from surgery and radiation
A recent article by authors Drazer et al.[i] from the University of Chicago confirms that the pendulum had swung too far in favor of screening, at least for older men with limited life expectancy. The study analyzed the experience of men age 65+ who did had been offered screening but did not have PCa. The authors especially focused on those who were predicted to have 9 years of life expectancy based on other health problems. Why 9 years? Because the majority of PCa cases that are diagnosed early—with the exception of some very aggressive cell lines—take at least 10 years to progress to lethality. It’s generally accepted that there’s little point in putting a man through an aggressive PCa treatment if he is more likely to die sooner from another disease or condition. This raises one question indirectly raised by the Panel: then why screen them at all? Drazer and his cohorts found that average screening rates for their study population had held steady from 2005 to 2010 (48% screened). They reported that in 2010 a third of older men with a 9-year life expectancy “were screened despite minimal clinical benefit.” The team also found that twice as many men recalled talking with their doctors about the advantages of screening compared with the disadvantages. With hindsight, this article justifies the Panel’s concerns that men were being screened who did not need it, with the majority apparently not being told there were disadvantages for men in their circumstances.
A second article shows how a large managed care organization, Kaiser Permanente Southern California, actually preceded the Panel’s recommendation and by 2008 had started pushing the pendulum back the other way. Using the electronic files of 15,326 men who were screened, biopsied and treated from 2000-2012, Wallner et al.[ii] compared annual rates of PSA testing, elevated PSA tests, biopsies and treatment (surgery and radiation). They stratified the men by age groups. Within their organization, beginning in 2008 their screening rates diminished as follows:
- 59% decrease for men age 75 and older
- 49% for men ages 65-74
- 20% for men ages 50-64
- 33% for men ages 40-49.
For all groups except the first, the number of elevated PSA results stayed about the same; for those aged >75, however, there was a 45% drop in elevated results. Although Kaiser’s screening reduction was ahead of the Panel’s 2012 decision, their prostate biopsy rates “remained constant, and subsequent prostate cancer treatment remained highest among men in this age group [>75 years].” It remains to be seen if their male urology patients ultimately benefit from reduced screening rates. I can’t help but wonder, though, if shorter life expectancy for those in the oldest age brackets was taken into account before putting them through treatment that may have left them with less quality of life in their remaining years.
[i] Drazer MW, Prasad SM, Huo D, Schonberg MA et al. National trends in prostate cancer screening among older American men with limited 9-year life expectancies: evidence of an increased need for shared decision making. Cancer. 2014 May 15;120(10):1491-8.
[ii] Wallner L, Hsu J, Loo R, Palmer-Toy D et al. Trends in Prostate-specific Antigen Screening, Prostate Biopsies, Urology Visits, and Prostate Cancer Treatments From 2000 to 2012. Urology. 2015 Jun 27. pii: S0090-4295(15)00587-7. doi: 10.1016/j.urology.2015.04.063. [Epub ahead of print]