Benjamin Franklin is quoted as saying nothing can be said to be certain except death and taxes. Perhaps he didn’t include aging because a) at the time of his death in 1790 the average male life expectancy was 38, or b) he led a rich and vigorous life almost till his death at age 84 so maybe he didn’t see himself as old.

Whatever the explanation, Franklin was not a victim of ageism because in his day, ageism didn’t exist. The term wasn’t even in our vocabulary until 1968 when gerontologist Robert Butler coined it to define “the process of stereotyping and discrimination against people because they are old.” Social research has identified that a bias against older adults is present in medical care, but it’s not an easy problem to solve. According to a 2019 published review, ageism in healthcare “… is not easy to identity and fight ageism in practice, as the identification of multiple manifestations of ageism is dependent on the way it is defined and operationalized.”^[i]

Your PSA as you age

One area of aging men’s health that is hopefully free from stereotypes is prostate cancer (PCa) screening. The newest guidelines, published in July 2023^[ii], state that the PSA blood test should still be the first-line choice in early detection, based on evidence driven reduction in metastasis and death. Then, the authors acknowledge the need for “screening in different groups based on their age range and risk criteria, with an emphasis on SDM (shared decision making).”

Why should age be taken into account? Well, a healthy man’s PSA generally starts to increase as he grows older. When I first began practicing medicine, the rule of thumb was any PSA above 4.0 ng/mL was grounds for a biopsy. By that standard, how many hundreds of thousands of men in their 60s and 70s were subjected to needle sampling when their normal PSA was higher than that benchmark? Therefore, the threshold for suspicion of PCa should be lower for younger men, and higher for older men. As the guidelines point out, “Most studies identifying age-varying thresholds specify threshold values of 2.5 ng/mL for people in their 40s, 3.5 ng/mL for people in their 50s, 4.5 ng/mL for people in their 60s, and 6.5 ng/mL for people in their 70s.”

Shared decision making (SDM)

Another way the guidelines indirectly take aging into account is the practice of shared decision making (SDM). The four characteristics of SDM are spelled out in the new guidelines:

1. Involvement of both the clinician and the patient in the decision-making process,
2. Sharing information by both the clinician and the patient,
3. Building consensus through the expression of preferences by both clinician and patient, and
4. Agreement by both the clinician and patient on the decision to implement.

It’s important to recognize that our preferences change as we age. Factors that can influence our priorities include larger knowledge and experience base, gradual shift in physical energy and strength, potential development of new health conditions such as diabetes or cardiovascular disease, work and retirement issues, changes in one’s intimate relationship, etc. Also, other risk factors may play a role in the frequency of screening. Thus, SDM affords an opportunity for an individual to explain any age related shift to his doctor, and for the doctor to listen closely to help overcome any unconscious bias toward older men.

My last point about the latest guidelines is the inclusion of multiparametric MRI (mpMRI) in the screening/diagnosis pathway. The authors cite expert opinion that a newly elevated PSA should first be followed by a repeat PSA within some months as indicated by individual case. Then, the need for biopsy would be determined based on suspicion of clinically significant PCa based on clinical, laboratory and mpMRI results (or other imaging such as PSMA/PET if advanced/metastatic disease is suspected).

The bottom line is, respect the evolving shifts in the physical, mental and emotional world of each man as he ages. This applies to PSA screening as much as any other part of a man’s world after midlife. The newest guidelines for early detection, starting with PSA, thankfully respect the aging process. Since our average life expectancy appears to be slowly increasing, with concomitant growth in newly diagnosed PCa, this will benefit us all.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] José Manuel Sousa São José, PhD and others, Ageism in Health Care: A Systematic Review of Operational Definitions and Inductive Conceptualizations, The Gerontologist, Volume 59, Issue 2, April 2019, Pages e98–e108.
[ii] Wei JT, Barocas D, Carlsson S, Coakley F et al. Early Detection of Prostate Cancer: AUA/SUO Guideline Part I: Prostate Cancer Screening. J Urol. 2023 Jul;210(1):46-53.