Cancer (and prostate cancer) screening in the elderly

The value of regular testing of increasingly elderly men and women for risk of cancer is controversial. However, a new paper in the Archives of Internal Medicine has certainly added to our knowledge of just how widespread such testing may be … at least in the USA.

Bellizzi et al. set out to estimate the prevalence of cancer screening in a racially diverse cohort of adults of ≥ 75 years of age. To do this, they looked at data from the National Health Interview Survey, which is a national survey based on annual, in-person interviews, and is used to track health-related trends and behaviors across the U.S. civilian population. Specifically, individual “screening” behavior was analyzed for breast, cervical, colorectal, and prostate cancer risk, and was correlated against the recommendations of the U.S. Preventive Services Task Force.

Here are the study findings:

  • The full analytic sample cohort included 49,575 individuals.
    • 1,697 individuals were between 75 and 79 years of age.
    • 2,376 individuals were ≥ 80 years of age.
  • Among those aged 75 to 79 years, the percentages tested for cancer were as follows:
    • 57 percent were tested for colorectal cancer.
    • 62 percent were tested for breast cancer.
    • 53 percent were teated for cervical cancer.
    • 56 percent were tested for prostate cancer.
  • Among those aged ≥ 80 years or older, rates of screening ranged from a low of 38 percent for cervical cancer to a high of 50 percent for breast cancer.
  • Unadjusted screening prevalence rates differed by race and ethnicity; however, these differences could be accounted for by low education attainment.
  • Physician recommendation for a specific test was the largest predictor of screening.
  • > 50 percent of men and women older than 75 years report that their physicians continue to recommend screening.

The authors concluded that, “A high percentage of older adults continue to be screened in the face of ambiguity of recommendations for this group.”

This paper has received wide publicity. Several commentators have made points with which The “New” Prostate Cancer InfoLink is in complete agreement. These include the following:

  • That screening of the elderly for risk of cancer needs to take careful account of
    • The reasonable life expectancy of the individual (based on his or her physiological age)
    • Any co-morbid conditions of the individual that may impact life expectancy
    • The fundamental possibility of treatment if screening results are positive
    • The risks and benefits of treatment if screening results are positive
  • That a conversation about the value of continuing testing should be held between physician and patient so that the patient is making an informed decision about whether to continue such testing

We can not go on simply testing everyone in the way that we have in the past, regardless of other realities. In the case of prostate cancer, we are well aware that 80 percent of men of 80+ years of age will have pathologically identifiable cancer cells in their prostates. We are also well aware that the vast majority of 80-year-olds are not going to die of prostate cancer if they are diagnosed at that age with low-risk, localized disease.  Are there some 80-year-olds who have a 15-year life expectancy, are in excellent health, and who — if diagnosed with Gleason 7 to 10 prostate cancer in their early 80s — could really benefit from immediate treatment? Yes there are. But we must be able to find a better way to identify these men than through the continuing use of PSA-based screening.

9 Responses

  1. It is a huge problem, at least in my family. In the last 2 years my 82-year-old father was told his PSA was around 10 and that he should get a biopsy (he died a few months later of unrelated, but already existing causes), my 92-year-old (and quite frail) father-in-law was told his PSA was 20 and that he should have a biopsy, and my 102-year-old grandmother was told she should have a mammogram. It is extremely unlikely that any of them would even survive treatment if anything was detected, much less have any sort of improvement in quality of life for their remaining months/years should the cancer be successfully “cured”. (I put “cured” in quotes since none of them are ever going to be affected by a cancer that might be detected early through screening at this stage of their lives.)

    All this has accomplished is to cause serious, entirely unnecessary, emotional stress for my family members. My father-in-law is particularly concerned about his PSA and brings it up every time I see him. It is very difficult having to explain that complications from a biopsy are a much bigger threat to his health at this point than a possible cancer that has raised his PSA to only 20 ng/ml at age 92. People don’t need to be reminded constantly that they are probably going to die any day now of something else anyway.

  2. If the cancer is in its early stages, treatment may not be required. The doctor will advise you to wait and watch for the symptoms. If the cancer is still progressing, then you may consider either surgery or radiation treatment. Initially radiation therapy is recommended, if there is not any improvement in your conditions, surgery can be considered as a last option.

  3. Dear Harry:

    I think you are missing the point entirely. Please read Jim West’s comments above, which show a real understanding of the problems elderly people and their families are facing when “eager beaver” physicians fail to address (or even think about) the realities of inappropriate diagnosis.

  4. Mike,

    Jim’s case is clearly understandable and an example of inappropriate practice. That said, let me give you a case that I am living in my own family. Recently one of my cousins called me to ask some prostate cancer questions. He is 79 years old, on Avodart for BPH, and was recently diagnosed with prostate cancer “with two very small points of cancer on one side” of his prostate (his words).

    After I told him to slow down and seek a second opinion for his Gleason 6 (3 + 3) biopsy, he agreed to do so and to call me back. He never did and in talking to his sister 2 days ago, she tells me he is going to have robotic surgery in January. It is his decision (with which I do not agree), but not all cases are as clearly defined as Jim’s. Genetically my cousin has many years to live. I just hope his QOL is not impacted by his decision. … :-(

  5. Dear Ralph:

    I would love to know what his urologist has been telling your cousin! It would be amazing to me if his quality of life was not impacted by this decision.


  6. My 79-year-old father was diagnosed 4 months ago with prostate cancer. Hormone therapy was started and he requested a bone scan, which found a mass between the kidney and the bladder. Two weeks ago went in for surgery on the mass and was told that one kidney was/is not working properly. A stent was placed to bypass the kidney temporarily after as much of the mass was removed as possible. He finally was able to actually talk to an Oncologist, who looked at his case, and said that he fears that the cancer has spread to his spine (possibly explaining the still ongoing back pain). He was told that his Gleason score is 9 and in his doctors words, “if this is the case there is nothing they can do for you.” He is now experiencing severe stomach pain and vomiting, and is barely able to muster up the energy to walk from the couch to the bathroom. This is not like him. He is truly scared, angry, and confused, as is to be expected. My mother is having trouble accepting that there is nothing that can be done.

    I do understand that the age is an issue but otherwise a healthy and active man has now become a couch potato and not by choice.

    Can some one give me some help.

  7. Dear Sally:

    We are going to need some more information if we are to be able to assist you and your father. The best thing for you to do is to go and join our social network, where we can talk with you over time about some possibilities. When you join the social network, please try to tell us what your father’s PSA level was when he was diagnosed with prostate cancer. This may be important. It might be wise for your Dad to go back to his oncologist to talk about getting a different type of hormone therapy (depending exactly what he has been getting). You should also try to tell us what type of hormone therapy you Dad has been getting.

  8. My dad lives in Hawaii and I in California, so the information is minimal unless I know exactly what to ask him for. Even then I am not really sure that he can give me the answers. Sounds like I may need to take a trip.

  9. Nice post. Thanks. It’s really helpful.

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