A diabetic man aged 76 with no history of prostate cancer (PCa) comes to his primary care physician (PCP) for his annual wellness visit. (Sidebar: in the good old days they were called physicals, but in today’s Medicare world, they’re annual wellness visits—and yes, there is a difference but that’s for another day.) He fasted the night before because, as a diabetic, his Medicare will cover his lab work. As an add-on, his PCP orders a PSA test, which the patient has had every year since his late 50’s.
Major professional societies such as the American Urological Association and the American Society of Clinical Oncology recommend against PSA screening for elderly men with reduced life expectancy. In the case of our diabetic 76-year old, was the PSA justified? The screening recommendations by the US Preventive Services Task Force have fluctuated—revealing their concern about overdetection and overtreatment—but both patients and doctors still seem to value annual PSA screening starting somewhere around age 40, 45 or 50 depending on other risk factors. But how do you know when it’s time to stop screening?
How important is PSA screening after age 75?
No doubt you’ve heard that PCa is an old man’s disease, and that you’re more likely to die with PCa than from it. Broadly speaking, it’s true. With aging, cellular structures can degrade and become more prone to mutations, including cancer. Autopsy studies have shown that almost 30% of men over the age of 50 have evidence of undiagnosed PCa [i], and by age 80+ it is closer to 47% among Caucasian men.[ii]
The issue is, better health awareness and accessible health care means that more men are living longer. While an individual’s life expectancy depends on many factors like family history, lifestyle habits, coexisting conditions, etc., the fact is that a rising number of elderly men are diagnosed with PCa.[iii] Although the majority of cases will have insignificant cell lines that likely pose no threat, even in heavily screened populations there is evidence that “…aggressive disease was more common as men age…; elderly men quite frequently have clinically significant prostate cancer, and that some of these men would benefit from definitive therapy.”[iv]
Here are some numbers from one study that underscore the importance of screening from age 75 on:
- Men older than 75 represented 52% of men with metastatic PCa at time of diagnosis
- Men over 75 contributed to 47% of PCa-specific deaths
- Men over 75 who died from PCa lost roughly 75% of their remaining years of life.[v]
The authors hypothesize that at least in part, less screening and fewer diagnostic tests can lead to these sad figures. To me, the numbers are persuasive that PCP’s should continue screening their older male patients, especially those who enjoy otherwise good health and can anticipate many more years of life to come.
Treatment considerations for elderly men
It’s possible that PCP’s and even urologists are unwilling to screen after a certain age out of concern that surgery or radiation would be too harsh for elders subject to the frailties that come with growing older. There is certainly some justification for this view, given that whole gland treatments put stress on the body and risk inflicting side effects that harm quality of life. Why put a 75- or 80-year old through that if it can be avoided?
Instead, there’s an alternative. Focal PCa therapy, such as our MRI-guided Focal Laser Ablation (FLA), is a minimally invasive, highly targeted outpatient procedure with little or no effect on urinary or sexual function. In addition, there’s no general anesthesia so that’s one more less risk. For carefully qualified patients, especially elderly men with a potentially aggressive cell line, FLA offers the advantage of destroying the tumor without damaging lifestyle.
The knowledge that there’s a minimalist yet effective treatment for older men with localized PCa should be reassuring for physicians who are on the fence about whether to give PSA tests to their senior citizen patients. Focal therapy can provide the confidence needed to counter the temptation to neglect screening for today’s Golden Agers.
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] Scardino, P. Early detection of prostate cancer. Urol Clin North Am. 1989 Nov; 16(4):635-55.
[ii] Jahn JL, Giovannucci EL, Stampfer JM. The High Prevalence of Undiagnosed Prostate Cancer at Autopsy: Implications for Epidemiology and Treatment of Prostate Cancer in the Prostate-Specific Antigen-Era. Int J Cancer. 2015 Dec 15; 137(12): 2795–2802.
[iii] Stangelberger A, Waldert M, Djavan B. Prostate Cancer in Elderly Men. Rev Urol. 2008 Spring; 10(2): 111–119.
[iv] Vellekoop A, Loeb S. More aggressive prostate cancer in elderly men. Rev Urol. 2013; 15(4): 202–204.
[v] Scosyrev E, Messing EM, Mohile S, Golijanin D, Wu G. Prostate cancer in the elderly: frequency of advanced disease at presentation and disease-specific mortality. Cancer. 2012 Jun 15;118(12):3062-70.