Over-use of PSA testing in men > 65 with short life expectancies?

Why is it that we seem to be so focused on testing for risk of prostate cancer in older men with life expectancies of < 10 years, i.e., men who are almost certainly at very low risk for clinically significant disease?

We raise this question because of a newly published paper by Royce et al., which shows that, among the 27,000+ participants in the National Health Interview Survey (NHIS) from 2000 through 2010, all aged 65 years or older:

  • Of the participants with a high risk of dying within 9 years, 31 to 55 percent had received recent cancer screenings.
  • Screening for prostate cancer was the most common form of test (among 55 percent of the men at high risk for death within 9 years), although …
  • Very high vs low mortality risk was associated with less screening for prostate cancer (odds ratio [OR] = 0.65).
  • Screening for prostate cancer among high-risk men was less common in more recent years compared with 2000.

One of the key problems here may be the fact that all too many men in America simply don’t see a doctor at all (unless they have to) until they reach retirement age and become eligible for Medicare. There are two possible reasons for this. The first is that, until they reach 65 years of age, all too many men simply have no health insurance coverage at all, and so seeing a doctor is an expensive business, especially if they are going to have tests done that they must pay for out of their own pockets. The second is that all too many men live under the delusion that it is “unmanly” in some way to need to see a doctor … so they just don’t (unless they absolutely have to) — even though they should.

Given these two premises, it is arguably unsurprising that there is a high level of PSA testing among men over the age of 65 who have a high risk for mortality within 10 years. Why? Because in many cases this testing may be occurring at their first serious health evaluation since they were a child, so they get a full battery of tests, including a PSA test, and these tests then show that they have a range of possible health risks. For a proportion of those men, it is then recognized that they have a high risk for mortality within the next 9 years.

A man who has, over time, had regular health checks, and has shown no sign of risk for prostate cancer (on a rectal exam or a PSA test or for other clinical reasons) is unlikely to suddenly start benefiting from PSA testing at age 65. And a man who has, over time, had regular health checks, and has shown no sign of risk for prostate cancer but has other co-morbidities and a high risk for mortality from other causes within 10 years is highly unlikely to benefit at all from starting PSA testing at age 65. (Yes, there will be occasional exceptions to this general rule; there are always exceptions to general rules.)

What The “New” Prostate Cancer InfoLink sees in the data reported by Royce et al. is not necessarily unreasonable over-use of the PSA test in sick men of 65 years of age and older. Rather, these data probably reflect a combination of factors that include:

  • Failure of many American men to take their own health seriously during their working lives
  • The long-term lack of access to basic health services for many Americans until they reach retirement
  • The relatively thoughtless use of “batteries” of tests by primary care physicians to “screen” new patients (whether the tests are actually needed or not) — which reflects the lack of time that primary care physicians often have to spend with their patients today, and also the way batteries of tests are (very reasonably) used to “catch” a wide spectrum of risk information
  • A dramatic change in the behaviors of men with respect to their own health care once they retire and “have time on their hands,” and because after they have retired it becomes socially acceptable to acknowledge the idea that they might need healthcare services if they want to enjoy their retirement.

What is very useful about the paper by Royce et al. is that it forces us to ask why we are seeing the behavior patterns that they record and what can be done to ensure that we are acting in the most sensible possible manner moving forward.

One Response

  1. I spent several years teaching at an inner city school and have been in more homes of those living in poverty than most. Those people have nothing. They have not been to the doctor because they just cannot afford it. There are children who will not see a doctor until they are adults. If ever. And anyone who has been in the Medicaid system knows the problems. It sucks.

    So for me, it is easy to see why the Affordable Care Act was passed. In the US we had 40 million people with no health insurance. Wow. The “60 Minutes” piece on states that have refused Medicaid federal funding showed quite clearly the health issues that so many Americans are dealing with.

    But what is most fascinating is the ACA success in Kentucky right now. Hundreds of thousands of people in that state have health care coverage for the first time in their lives. Is it reasonble to think that their new-found health care will allow people to be checked out earlier, before heart disease, obesity, breast, and prostate cancer? Of course. Will it take time? Are you kidding? Why are we just now figuring this out?

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