There is an interesting article on Kaiser Health News today discussing the risks associated with “over-testing” of elderly and sometimes very infirm people who are at relatively low risk for specific chronic diseases, including prostate cancer.
… increasingly, questions are being raised about the over-testing of older patients, part of a growing skepticism about the widespread practice of routine screening for cancer and other ailments of people in their 70s, 80s and even 90s. Critics say there is little evidence of benefit — and considerable risk — from common tests for colon, breast and prostate cancer, particularly for those with serious problems such as heart disease or dementia that are more likely to kill them.
Many years ago, there was a question to Ask Arthur from a distraught family member about a man of 92 in a long-term care facility. The gentleman had just been given a PSA test which had come back at 4.2 ng/ml. He had never previously had a PSA test. Now the doctor had scheduled him for a biopsy. However, the gentleman in question was suffering from dementia, was already largely confined to bed because of his general health and, even in the most optimistic scenario, the idea that he would live to see 100 years was simply not on the table. Why anyone would have given this gentleman a PSA test at his age and given his long-term health outlook is hard enough to imagine. The idea that one might actually biopsy such a gentleman is borderline insanity. His risk for clinically significant prostate cancer during his lifetime was probably about as close to zero as one could reasonably expect in a man with his PSA level.
The question for today is therefore, “When would you tell your father to stop having PSA tests?” We shall assume that your father has been having them every so often since he was 50 years of age, and that his last PSA level was 2.8 ng/ml at age 76. The implicit issue is — as illustrated above — when would having a PSA test bordering on the high level of “normal” no longer be a significant indicator for biopsy in a specific patient if there were no other indicators of risk? One can ask a similar question about many other tests used to screen men and women for a variety of chronic illnesses. The most recent data, for example, appear to suggest that people who have had even one colonoscopy after age 50 with no indication of polyps are actually at extremely low future risk for colon cancer.
The era of personalized medicine is not only going to be about what we are able to know about and do for patients on an individual basis. It is also going to be about what we do not need to know about and what we do not need to do for patients on an individual basis. There are going to be fathers like the one above who come from families with significant risk for prostate cancer (in one genetic line) but also a history of significant longevity with good quality of life (in three other genetic lines) when their genealogy is explored. Is it reasonable to go on giving such fathers regular PSA tests until they are 80, 85, or 90 years of age? Even if one did, and his PSA suddenly came back at 4.5 ng/ml at age 85, would you think he should have a biopsy?
The converse situation is also reasonable. We know that 5 in 6 men will never be diagnosed with prostate cancer in their lifetimes. The current author has been having PSA tests pretty regularly since he was 50, as required by his insurance company. At no time has there been any reason to suggest the need for a biopsy, and (as far as he is aware) he has no family history of prostate cancer in the past 200 or so years — despite a family history in which reaching one’s 90th birthday has been a relatively commonplace event. At 63+ years of age, does he really need to go on having PSA tests after age 70? His risk for prostate cancer appears to be minimal.
The “New” Prostate Cancer InfoLink does not think that “cut off dates” are an appropriate way to think about whether individual men should or should not get PSA tests. In other words, the idea that no man over age 75 needs a PSA test is inappropriate. However, we do believe that the idea that one should go on having PSA tests long after one’s life expectancy is less than 10 or even 15 years is also a less than great idea unless there are good individualized reasons to do so. We are all going to die of something. The idea that screening tests for certain types of chronic health condition will help one to “maintain one’s health” after one’s life expectancy starts to decline significantly is not supported by any data that we are aware of, and the costs to society are massive.
To quote once again from today’s article in Kaiser Health News:
Alan Pocinki, an internist who practices in the District, said he tried to persuade an 80-year-old patient, a survivor of several heart attacks, to stop PSA testing. The man’s son, a Boston oncologist, agreed with Pocinki, but the patient insisted.
The elevated reading led to a biopsy, which found cancer. Pocinki said the patient contracted a serious infection from the biopsy, his cancer is being monitored through “watchful waiting,” and he has repeatedly said he wishes he’d never had the test. “He always tells me, ‘I know you told me not to do it.’ “
We all have a responsibility to use health care capabilities with social and economic responsibility. As we age, we need to take that responsibility very seriously, because the benefits that can accrue to us from appropriate use of the system far outweigh the possible risks associated with over-use.