Prostate cancer is the most common cancer, other than skin cancer , affecting men in the US. According to the American Cancer Society (ACS) 220,900 new cases of prostate cancer will be diagnosed in 2003 and approximately 28,900 men will die of the disease.

Elevated levels of prostate specific antigen (PSA) in the blood may be an indication of prostate cancer. This is why most physicians generally recommend annual PSA screening in men beginning between the ages of 45-50 (depending on risk factors). This is despite the fact that there is no convincing evidence to date that PSA screening actually reduces the risk of dying from prostate cancer.

Since prostate cancer is often (but not always) a slow growing cancer, most guidelines do not recommend PSA screening for men over the age of 75. This is because although the risk for prostate cancer increases with age, it is unlikely that prostate cancer detected in a man over the age of 75 will progress to the point where it will harm him during his lifetime.

Nevertheless, the rate of PSA screening in elderly men appears to be quite high. Recently, a group of researchers set out to determine the reason for this high screening rate. They conducted a study designed to answer two important questions: Who is driving the high rate of PSA screening in elderly men? And, are the patients being informed of the risks and benefits of PSA screening prior to the test? Their study, published in the December 3, 2003 issue of the Journal of the National Cancer Institute, found that the vast majority of the men who underwent screening did so at their doctor’s suggestion, but only two-thirds discussed the risks and benefits of PSA screening with their doctors prior to having the test.

About the study

A group of researchers reviewed information on PSA screening from 7889 men who participated in the 2000 National Health Interview Survey (a continuing, population-based, multistage health survey). These men had not been diagnosed with prostate cancer but had undergone a PSA test within the past year. The researchers focused their attention on the men’s responses to three questions:

  • What was the main reason you had this PSA test? (Screening or other)
  • Who first suggested the PSA test? You, your doctor, or someone else?
  • Did your doctor discuss the advantages and disadvantages of the most recent PSA test with you before doing it?

The findings

The researchers found the following screening rates for the 7889 men surveyed:

  • Men aged 45-54 (17.8%)
  • Men aged 55-64 (31.2%)
  • Men aged 65-74 (40%)
  • Men aged 75-79 (38.8%)
  • Men aged 80 and over (24%)

Based on these results, the researchers estimate that as many as 32.5% (1.47 million) men over the age of 75 were screened for prostate cancer in the year 2000.

The researchers also found that of those who were screened with PSA, 88.4% did so based on their doctor’s suggestion, but only 66.5% of the men discussed the risks and benefits of PSA screening with their doctors prior to having the test.

How does this affect you?

The researchers concluded that no clear strategy exists for PSA screening among elderly men based on an understanding of the risks and benefits of screening in this population. Even in light of the current controversy, it does not, at this juncture, seem reasonable for doctors to routinely recommend PSA testing to their elderly patients when its benefits have not been clearly established.

The controversy over PSA screening closely resembles that over mammography and Pap smears in elderly women. Americans may not be comfortable with the idea of living with cancer, but does it make sense to perform screening tests such as PSA tests, mammograms, or Pap smears on people in their 70s in order to discover a disease that is unlikely to affect their lives?

While withholding potentially beneficial services from people based on their age is a dangerous precedent to set, it is important to remain mindful of the fact that these screening tests are not without risk. For example, side effects from prostate cancer treatment may include incontinence, erectile dysfunction, and discomfort from scarring. Additionally, there is the inherent anxiety in receiving a positive screening result, and needing to determine whether to undergo the risks of additional diagnostic tests and treatment.

In the end, of course, patients must ultimately decide what is in their own best interest. Physicians need to acknowledge the inherent controversies in cancer screening recommendations and take seriously their responsibility to discuss the risks and benefits of these tests before ordering them for their patients. Although there is certainly a place for aggressive screening and diagnosis of cancer, sometimes the best thing we can do for healthy elderly men and women is leave them alone.