PSA testing in men over 70 years of age — some perspective

A new report in the Journal of Clinical Oncology suggests that — at least between 2000 and 2005 — “excessive PSA screening in elderly men with limited life expectancies” was a significant problem, and may remain so today.

The role of PSA testing in older men with life expectancies of 15 years and less is controversial. The U.S. Preventive Services Task Force (USPSTF), when it last reported on this topic, recommended that prostate cancer testing was inappropriate in men aged 75 and older. By comparison, The “New” Prostate Cancer InfoLink has always felt that the Iowa Consensus position is more appropriately nuanced. Having said that, there clearly does come a point at which continuing to give PSA tests to elderly males with no prior evidence of prostate cancer becomes a pretty pointless exercise. Are we going to actively treat most of men of 85 years of age for localized prostate cancer if we actually find it? We sincerely hope not. Will there be rare exceptions? Probably.

Drazer et al. (with a full appreciation of the nature of the controversy) set out to describe the rates and predictors of PSA testing among older men in the United States.

They used as their database the population-based 2000 and 2005 National Health Interview Survey (NHIS). “PSA screening” was defined as the use of a PSA test as part of a routine exam within the preceding year. The NHIS collected demographic, socioeconomic, and functional characteristics, and a validated 5-year estimated life expectancy was calculated for all participants.

The results of the study showed the following:

  • The PSA screening rate was 24.0 percent in men aged 50 to 54 years.
  • The PSA screening rate increased steadily with age until a peak of 45.5 percent among men of age 70 to 74 years.
  • Among men of > 74 years of age, screening rates then gradually declined by age.
  • The PSA screening rate was 24.6 percent among men aged 85 years or older who reported being screened.
  • Among men aged 70 years or older, screening rates varied by estimated 5-year life expectancy:
    • For men with high life expectancies (≤ 15 percent probability of 5-year mortality) the screening rate was 47.3 percent.
    • For men with intermediate life expectancies (16-48 percent probability of 5-year mortality), the screening rate was 39.2 percent.
    • For men with low life expectancies (>48 percent probability of 5-year mortality), the screening rate was 30.7 percent.
  • Estimated life expectancy and age remained independently associated with PSA screening in multivariate analysis.

Drazer and his colleagues conclude that — in the USA between 2000 and 2005 — rates of PSA screening were associated with age and estimated life expectancy.

Now there is very good evidence that, for men initially diagnosed with low- to intermediate-risk, truly localized prostate cancer, there is little to no clinical impact on their life within 5 years. This does tend to make one ask what the possible benefit could be to giving a PSA test to the vast majority of men with a life expectancy of 5 years or less? And yet (between 2000 and 2005) we were apparently giving PSA tests to 30-40 percent of such men and to about 25 percent of men of 85 years of age or more (most of whom, presumably, also had life expectancies of 5 years or less). Were most of these men actually asking for these tests, or were their doctors just giving them these tests as part of a routine? Are the same sorts of rates of PSA testing evident today in a similar patient cohort, or have the recommendation of the USPSTF and the results of the PLCO and ERSCP trials lowered these rates? We have no real idea.

The bottom line to all of this is that there is a major disconnect between what a PSA test can actually tell a doctor and his elderly patient and what a smart doctor and a smart elderly patient would actually do with that information. The question that all doctors (and their elderly male patients) probably need to be asking themselves is, “If you did or didn’t have PSA data in a man with a life expectancy of < 5 years (or perhaps even < 10 years) and no prior history of risk for prostate cancer, would it actually make any difference to your recommendations for his management?” The situation is clearly different for men who have shown prior risk for prostate cancer … but not a lot different if that history includes at least two prior negative biopsies.

11 Responses

  1. Mike:

    In spite of the possible over-treatment, it seems to me that much is ignored or unexplained about the mortality reduction in prostate cancer when men are tested with PSA. The ERSPC and Goteborg results support the Tyrol results. This study reports the lower use of PSA testing and the reason why still too many men die of prostate cancer because they are diagnosed with more advanced disease

  2. Ralph:

    I can’t make men go see a doctor. Every man has a responsibility to care for his own health. However, many men don’t get annual physicals, and they don’t even think about their health risks until it is way too late. Their risk for prostate cancer is miniscule by comparison with their risk for cardiovascular disease. Men tend to make worse health decisions than women, but as a society we do little to educate them.

  3. My PSA score has gone from 4 to 8 in 2 years. My PCP suggests a biopsy. I had one before. It was very painful and negative. Should I have another? I am 71 years old. I have no symptoms.

  4. Dear Mr. De Stephano:

    Before you have another biopsy, I would suggest you talk to your doctor about having a repeat PSA test in a couple of months time and also about asking him to get a %free PSA test using the same blood sample. If your PSA is still at 8 ng/ml or rising, and/or your %free PSA level is low (e.g., less than 15%), then you may indeed need to have a biopsy. The alternative is to ask your PCP to refer you to a urologist and then to have that conversation with the urologist.

  5. I have had high PSA scores over years: 4.50 in my 50s; 8.5 in my 70s; two biopsies negative. Going every 6 months for more PSA testing and prostate exam. Need for concern?

  6. Dear Monroe:

    Ask your doctor about giving you a Prostate Health Index test or a 4KScore test. It seems unlikely to me that you have clinically significant prostate cancer if your PSA has only risen from 4.5 to 8.5 ng/ml over 20 years. That sounds more like enlargement of the prostate or some form of mild prostatic inflammation. The two tests mentioned may be able to help rule out prostate cancer as a serious concern.

  7. I’m 74 years old and have a PSA reading of 7. Should I be concerned?

  8. Dear Ray:

    Well … It all depends on: (a) how long you expect to live (based on family history and whatever other health issues you may have had over the years); (b) how fast your PSA has been rising (if you know that); and (c) whether you are a worrier!

    The chances are high that actually, “No, you probably don’t need to be concerned”, but I’m not a doctor and I can’t make you any sort of guarantee (but then your doctors can’t can’t make you any sort of guarantee either). There are all sorts of reasons that a man of 70 might have a slightly elevated PSA like this — an enlarging prostate; prostate stones (like small kidney stones); mild inflammation of the prostate; etc. — as well as the fact that something like 70% of men of 70 years of age are found to have very small amounts of clinically insignificant prostate cancer in their prostates if they get autopsied when they die for other causes.

    The really important question, however, is, even if you did have a small amount of cancer in your prostate at your age, is it likely to lead to you either developing metastatic prostate cancer or killing you over the next 10 to 20 years? And the answer to that question is “Probably not.”

    If I was in your position I’d get another PSA test in a year’s time. If it was still about 7 ng/ml, I’d ignore the whole thing. If it had gone from 7 to 14 ng/ml, I’d go talk to my doctor about whether a biopsy might be a good idea. But I am not you and I am certainly not your doctor, so I think you need to have that discussion with your doctor.

  9. I am a 74-year-old male. Six years ago I had a negative biopsy when my PSA level was at 22 ng/ml.

    My PSA level recently was 55 ng/ml, and I was recommended to have a biopsy.

    My last biopsy was what I would define as very painful and crippling. I could barely walk a week later. I am very reluctant to have another one. although my 4K Score test came back as 96% risk for prostate cancer.

    I have been taking a supplement which is supposed to shrink the prostate and has lowered my PSA level to 39.5 ng/ml in 6 months time.

    I have a brother 1 year younger than I am, whom I contacted, and he has told me he has had BPH since 1975. When I asked him what his PSA level was, he reported it was 0.56 ng/ml. Is that a realistic number at 73?

    When I read of these men who are concerned about a PSA level of 8 or so, I think, my numbers are stratospheric in comparison. I have no symptoms of any kind. My urinary and sexual functions are fine and normal. What should be my concerns?

  10. Dear Ed:

    PSA levels are a measure of the amount of PSA a man is making in his prostate and of the “leakiness” of his prostate. So it is perfectly possible that you brother has BPH and a PSA of 0.56 and that you have a PSA of 55 ng/ml and some not very aggressive prostate cancer. Why do I say “not very aggressive”? Because it took 6 years for your PSA level to rise from 22 to 55 ng/ml.

    Having said that, if you have a PSA of 55 and a 4KScore of 96% risk, then there is a pretty high probability that you have prostate cancer. Is it going to kill you? I can’t answer that. You’d need a biopsy to tell you. I have no idea why your last biopsy was so painful. It could just have been done by someone who wasn’t very good at doing biopsies. If you really don’t want a biopsy (yet), ask if you could have an MRI instead. It won’t be able to give you an absolute diagnosis, but it might be able to tell you whether you really need that biopsy, and then you can ask for it to be done using a local anesthetic after you have explained how much of a problem it was the last time around.

    Oh, and by the way, a PSA of 55 ng/ml can occur without any sign of prostate cancer in a man with a large prostate. A “high PSA” would be one that was over 100 ng/ml. Some men get diagnosed with PSA levels in the thousands. And then some other men get diagnosed with PSA level of more like 2.0 ng/ml.

  11. Thank you for your informative reply.

    I have just recently heard of an MRI as a tool to better inform me about the need for another biopsy. I like the idea of a local anesthetic, too. I will have to go back to my assigned urologist and see if he would accommodate me on this as I have ignored his calls and “certified” letters.

    My cardiologist/internal medicine doctor has also asked me why I haven’t pursued this. I told him that I learned from the AUA that after 75, PSA tests are not recommended. He asked me how old I was. “74” was my answer. So, they have another 6 months to go after me, I guess?


    Arthur responded as follows:

    Dear Ed:

    Arthur says that you don’t “have to” do anything about this if you don’t want to. It’s your life, not theirs. However, the better informed you are the better the decision you will be able to make. So …

    Arthur says that if we assume that you had a biopsy, and your Gleason score was (say) 3 + 4 = 7, and you decided to do nothing at all about it at all, then according to the prostate cancer-specific Male Life Expectancy calculator on the web site of the Memorial Sloan-Kettering Cancer Center, if you are otherwise in excellent health, it can be projected that:

    — 10 years from now (i.e., when you are scheduled to be 84 years old), for 100 men like you, 7/100 would have died of their untreated prostate cancer; 37/100 would have died of something else entirely; and 56 would still be alive.

    — 15 years from now (i.e., when you are scheduled to be 89 years old), for 100 men like you, 10/100 would have died of their untreated prostate cancer; 61/100 would have died of something else entirely; and 29 would still be alive.

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