Cost and prevalence of PSA testing in Medicare patients > 70 years old


A recent article in Cancer has stimulated media coverage of the appropriate role of PSA testing in men of > 70 years of age and costs covered by Medicare for PSA tests in men over this age.

The original article by Xiaomei Ma et al. in Cancer was supported by media information from Yale University and covered by stories appearing in The Plain Dealer and on the HeathDay web site.

Basically, Ma et al. assembled a population-based cohort of male Medicare beneficiaries aged 66 to 99 years, who had never been diagnosed with prostate cancer through December 31, 2006. They then tracked Medicare spending on this group of nearly 95,000 men for 3 years to assess

  • The basic costs of PSA screening among these men
  • The costs of associated, downstream procedures (including biopsy, pathologic analysis, and hospitalization due to biopsy complications)

Their study showed that:

  • 51.2 percent of the men received PSA screening tests during the 3-year period.
  • 2.9 percent of the men underwent a consequent biopsy.
  • Annual Medicare expenditures on prostate cancer screening and associated downstream procedures were $447 million in 2009 US dollars.
  • The mean annual screening cost at the hospital referral region (HRR) level ranged from $17 to $62 per beneficiary.
  • Downstream biopsy-related procedures accounted for 72 percent of the overall screening costs and varied significantly across regions.
  • Compared with men residing in HRRs that were in the lowest quartile for screening expenditures, men living in the highest HRR quartile were
    • Significantly more likely to be diagnosed with prostate cancer of any stage (incidence rate ratio [IRR] = 1.20)
    • Significantly more likely to be diagnosed with localized prostate cancer (IRR = 1.30)
    • More likely to be diagnosed with regional/metastasized cancer (IRR = 1.31), but this risk was not statistically significant.
  • The men being routinely given PSA tests included men > 75 years of age (including men in their 80s and 90s).

The authors formally conclude that

Medicare prostate cancer screening–related expenditures are substantial, vary considerably across regions, and are positively associated with rates of cancer diagnosis.

However, in other media individual authors of the paper are quoted as making additional statements, such as the following:

Our results suggest that the overall cost of prostate cancer screening may be heavily influenced by how urologists choose to respond to the result of a PSA test, more so than the use of the PSA itself.

and

In a time when healthcare spending is soaring, it is important to weigh the physical, psychological, and financial burden of cancer screening against the possible clinical benefit, The cancer research community needs to continue exploring novel approaches to target prostate cancer screening and treatment efforts, identifying and disseminating strategies that work, and abandoning strategies that don’t work.

The role of annual PSA testing in men of 70+ years of age is becoming increasingly controversial. In its most recent guideline on this topic, the American Urological Association advised that routine PSA testing is not recommended in men of 70+ years of age, or in any man with less than a 10-15 year life expectancy, although “some men age 70+ years who are in excellent health may benefit” from such testing.

However, for the patient community, the right to PSA testing among otherwise relatively healthy men in their 70s is a key issue, and The “New” Prostate Cancer InfoLink sees no easy way to resolve the two very different viewpoints until we have a much better test for risk of prostate cancer than the PSA test. If we discover such a test, then the question that will arise is going to be, “Can we afford to use it?”

4 Responses

  1. And here we go with “money” trumping “life saving.” I turn 81 in 2 months. How would the medical community absolutely know that I would have lived this long if, back at 70, I had wanted a PSA test but the government decided that just maybe I wouldn’t live another 10 years, so was refused and required to go to my own expense if I wanted that PSA test despite being Medicare eligible? I know many men currently with or having been treated for our danged disease who were diagnosed after age 70 but still alive and intending to be around more years. Do you think that maybe back at 70 or more and wanting a PSA test that since my Mom lived to 96 and Dad to 95, that would be a reason to grant that PSA test? It should, particularly if I have/had no major other health issues. But with current thinking, it appears that money will trump life saving and the “elderly” will be shunted away from testing that could prolong their lives for many future years.

  2. Well said Sir!!

  3. Just think, aside from the medical cost saving, the savings from not paying Social Security. Is there a Grand Plan for us aging Boomers?

  4. LEVERAGE TO REFORM THE US PREVENTIVE SERVICES TASK FORCE (USPSTF)?

    There is a US leader who weighed in on the value of the USPSTF recommendations by getting a PSA test within months of publication of their recommendations, recommendations that were essentially against screening, last year. That leader had seen his own maternal grandfather die a lingering death from prostate cancer, and he has written and spoken about his own mother’s death from cancer, with months of battling with her recalcitrant health insurer prior to her death. That political leader is President Barack Obama, and that experience of his family’s pain, suffering and death from cancer is obviously and prominently etched in his set of goals.

    The USPSTF structure is in dire need of reform. Clearly, the panel that participates in formulating guidelines and votes on them lacks subject matter expertise for some of the vitally important topics with which it deals, yet the group also, obviously, lacks adequate humility and the willingness to seriously consider input that challenges its preconceptions and flawed understandings. The Task Force mistake that comes most prominently to mind is its guideline regarding prostate cancer screening, where the Task Force clearly blundered, but many of us suspect its recommendations regarding vitamin D and mammography are also flawed, and there are likely others with which I am less familiar.

    Having paid close attention to the writing, talks, and actions of President Obama, I believe he would be a willing and able ally in reforming the USPSTF. As he will be President for several more years, we have some time to leverage his role, but we need to get on with it.

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