It’s a fact. America’s population is aging. Lifespans are increasing due to medical and lifestyle advances, so a healthy 70-year old man’s life expectancy may be greater than his father’s was at the same age. Here’s another fact: prostate cancer (PCa), the most common tumor cancer in men, is considered a disease of aging. The average age at diagnosis is 66, but with aging the odds of developing PCa increase. It’s more than twice as likely to occur in men over age 70 than in younger men.
If a man is diagnosed with prostate cancer (PCa), one of the factors that influences his treatment choices is his life expectancy. According to a 2022 study out of Cedars-Sinai investigators, patients would like doctors to discuss their life expectancy as “a number of years (‘you’ll live until 90’) or as a survival probability (‘you have a 20% probability of living 15 years’) rather than as a generalization (‘you have a long life expectancy’).” A rule of thumb used by many urologists is, the longer a man’s life expectancy, the more aggressive his treatment should be; by this principle, a patient expected to live at least 10 years should have radical prostatectomy or powerful radiation. And yet, nearly half of men with early stage PCa and a life expectancy less than 10 years are still receiving such aggressive treatment,[i] often leaving them with urinary, sexual or bowel problems—in some cases, for the rest of their lives.
Because of this situation, current PSA screening guidelines recommend against screening for prostate cancer among men older than 70. Why? Because many that age or older have a life expectancy of less than 10 years. On the other hand, with men living longer, the actuarial tables used by insurance companies suggest the following life expectancies for men:
|Age||Life Expectancy in years|
Thus, the average man can reach age 77 and still expect 10 more years of life! And yet, the US Preventive Services Task Force recommends against PSA screening for men ages 70 and above. They reason that a) not every 70-year old will make it to 80, and b) conventional PSA screening often leads directly to a prostate biopsy, anxiety, and possible overtreatment with consequent side effects. Who wants their Golden Years to be tainted with diapers or ED, right? And yet, an April 2023 paper published in JAMA tells us that a survey of over 32,000 men aged 70 or older revealed that “the overall PSA screening rate was approximately 50%.”[ii] They labeled it as overscreening. Screening is good, but if it’s subjecting older men to aggressive treatment they don’t need, maybe it’s too much of a good thing.
But wait. Are 70-year old men really being overly screened? Evidence from a different direction offers good reason to continue screening for otherwise healthy 70-year olds. In 2021, a Canadian multicenter group published their study of PCa patients ages 75 and above. Their results challenged the generalization that older PCa patients should not be treated aggressively due to the assumption that they had less than 10 years of life left.
Using genomic testing to analyze PCa cells in patients >≥75, the Canadian team concluded that “…elderly patients with low-risk prostate cancer might harbor more aggressive disease than their younger counterparts. This suggests that standard well-accepted paradigm of elderly prostate cancer patients not being aggressively treated, based solely on their chronological age, might need to be reconsidered..”[iii]
There’s another way to look at the age/longevity question. Instead of the chronological age (counting from the day you were born), what if your doctor evaluates your biologic age? How “young” are you in terms of your fitness, genetic heritage, nutrition, exposure to carcinogens, and co-existing conditions or chronic diseases? I’ve had patients who are chronologically 74 but who have the heart of a 50-year old and the body of a 55-year old. They are nonsmokers, eat plant-forward diets, work out regularly, etc.
The bottom line is, a national guideline may be throwing the baby out with the bath. Instead of discouraging PSA screening as men enter their 70s, PSA screening among healthy aging men is a justifiable precaution. Even better, the need for a biopsy can be ruled in or out by a multiparametric MRI of the prostate. To conclude, late-age screening is not too much of a good thing. As men live longer, healthier lives, let PSA screening followed by MRI help them continue to enjoy a long life free of PCa.
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.
[i] Daskivich TJ. The Importance of Accurate Life Expectancy Prediction in Men with Prostate Cancer. Eur Urol. 2015 Nov;68(5):766-7
[ii] Kalavacherla S, Riviere P, Javier-DesLoges J, et al. Low-Value Prostate-Specific Antigen Screening in Older Males. JAMA Netw Open. 2023;6(4):e237504.
[iii] Goldberg H, Spratt D, Chandrasekar T, Klaassen Z et al. Clinical-genomic Characterization Unveils More Aggressive Disease Features in Elderly Prostate Cancer Patients with Low-grade Disease. Eur Urol Focus. 2021 Jul;7(4):797-806.