The man who wishes he’d never had the PSA test he demanded

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.

In this article, Broodman reports that:

… 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.

7 Responses

  1. People should exercise their judgement, if they have one. PSA testing should be conducted only in the context of considering what the follow-up could be: biopsy, first-line treatment, etc. If one’s mortality — based on combination of age, family history, medical condition — precludes a possible follow-up treatment, there is little point in testing.

    This is a difficult decision indeed, as proven by the story presented, in which both the treating urologist and the son (who is an oncologist) recommended not doing a biopsy, but were overruled by the patient.

    In any case, PSA testing for younger men should be continued in order to catch a possible prostate cancer early enough to be treatable through a relatively simple and cost-effective first line of treatment, such as prostatectomy or radiation.

  2. I strongly agree that PSA testing should be continued for younger men. In fact, I would go so far as to say PSA testing should be part of regular annual testing for all men beginning at age 35. This should catch almost all cancers at an early stage where it is treatable, if necessary.

    Over-treatment isn’t a result of having a positive prostate cancer diagnosis. It is the result of the medical advice provided and how the prostate cancer patient elects to respond.

    I firmly believe that a universal testing program in conjunction with a widespread and effective education program about the disease, all of the available treatment options and their consequences, would lift the veil of mystery and uncertainly about prostate cancer.

    Best regards, Robert

  3. Robert:

    That’s a point of view I have a very hard time agreeing with. There is a massive amount of data now to suggest that annual PSA testing is of minimal benefit for the vast majority of men. What we need is a much better test than the PSA test so that we only have to biopsy the men who have a high probability of the type of prostate cancer that places men at risk of clinically significant (as opposed to biologically apparent) disease.

  4. Hi Sitemaster:

    I have a very hard time agreeing with some of your perspective, also.

    I completely agree that we need a better test. I just attended the PCRI conference here in Los Angeles and heard some very interesting and positive developments.

    “There is a massive amount of data now to suggest that annual PSA testing is of minimal benefit for the vast majority of men.” There is significant data on both sides of this argument; the US study and the European study.

    “…for the vast majority of men.” I’m concerned about all men, including the minority of men who are helped by the PSA test, because I’m one of them.

    When our science arrives at the point where we have a thoroughly reliable test that can distinguish between prostate cancer and other conditions, and which can distinguish between benign and aggressive prostate cancer – according to data at the PCRI conference we now have identified 27 variants of PCa, we have a different discussion.

    Until then, my personal view is that universal testing combined with sound medical advice for diagnosed patients is critical and the best way to save lives. I guess I’m not swayed by the argument that the cost of testing 48 men to save the life of one is too great.

    That said, this remains one of the great prostate cancer debates and might even have an adverse affect on prostate cancer research funding.

    Differing perspectives and debate is always enlightening, though.

    Warm regards, Robert

  5. I strongly agree with not using age or PSA numbers on any test, treatment or non-test, non-treatment decision for prostate cancer. Every person and cancer is different and everything should be based on individual circumstances.

    I do not agree with your comment on colon cancer. I HAD a friend who had a colonoscopy at age 76: negative, no polyps. !8 months later he had bowel problems; a repeated colonoscopy and subsequent testing revealed advanced colon cancer which had metastasized to his liver; 3 months later he passed away.

  6. Wolfram:

    “Extremely low future risk for colon cancer” does not mean “none.”

    Your friend’s experience suggests that he had an abnormally aggressive type of colon cancer that may well have existed at the time of his colonoscopy at age 76 … but which was not visible on colonoscopy at that point in time.

    There are most certainly men of 76 years of age who are discovered to have aggressive forms of prostate cancer too, and those cancers can metastatize and lead to prostate cancer-specific mortality. However, they are relatively rare in men of that age.

    “We are all going to die of something.”

  7. I have to wonder about the 92-year-old man in a care facility who had this PSA test. Do these long-term care facilities make money by having their patients tested for disease? Why else would they have tests run on people who are too old and frail to withstand treatment for whatever would be found?

    This happened to my mother. She had an oral cancer screening at age 98 and she died at age 99, before I even received the bill for this screening. What would they have done if they found something? She was under some the care of some doctor hired by the care facility and I think it must be a way to generate income for the care facility. My mother never could have withstood any treatment even if something was found. I hate the use of medical care like this when others are told they are being tested too often. I agree with Robert, I too have relatives who had cancer found by routine screening and biopsies, not a waste of money in their eyes! My own dear husband has prostate cancer and we do not know how it will turn out. Even if he lives, the hormonal therapy that the doctor says will be necessary for the rest of his life has turned my husband into my roommate. While everyone keeps telling me how happy I should be that my husband is alive (and I am!!), they don’t understand that the spark that intimacy adds to a marriage is gone forever. I am thankful he is alive but I am in mourning for a romance that has died.

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