Are some docs and older patients too gung-go in screening for prostate cancer? Or are they not gung-ho enough?
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Are some docs and older patients too gung-go in screening for prostate cancer? Or are they not gung-ho enough?
By Howard Wolinsky
The uptake of prostate cancer screening might be expected to tail off in men 70 to 85 based on U.S. Preventative Services Task Force recommendations against routune screening going back nearly 20 years ago.
Instead, new studies show that the screening rates in these men remain about the same or are even higher than those found in younger men who are advised to be screened (assuming they have not already been diagnosed with prostate cancer). Prostate-specific-antigen (PSA) participation rates do drop in those 85 and above.
Some researchers say such screening puts older men at risk for overdiagnosis and overtreatment of prostate cancers unlikely to harm them. Risks for false positives increase with age. But some critics maintain that such screening can be a lifesaver for men over 70.
This can pose a dilemma for those who have never been diagnosed with prostate cancer. For those of us who have been diagnosed, screening, especially with PSA blood levels and Digital Rectal Exams (DREs), is part of the cost of doing the business of Active Surveillance, close monitoring.
Watchful Waiting, a predecessor to AS, took older men off screening but resulted in an epidemic of deaths, especially in some European countries. Critics of the approach say WW entailed too much waiting and too little watching.
Depending on the study, 40-50% of prostate cancer-free men below 70 down to 45 or 50, undergo PSAs, the target group for screening. Screening in Black men is recommended at age 45 because they have a greater risk for aggressive cancer though AS works fine for the right patients.
New studies show that screening in post-70s, who never have been diagnosed with prostate cancer, is at about the same level or a bit higher than younger men until they hit their 80s. Some researchers are sounding alarms over whether these men may become victims of overdiagnosis and overtreatment, resulting in another epidemic of impotence and incontinence.
Some advocates maintain that the USPSTF guidelines result in undertreatment and missed opportunities to detect and treat prostate cancer before it spreads.
Rick Davis, founder of the AnCan Foundation, which offers peer support, said researchers and the USPSTF are missing the point: "PSA testing is about information, not treatment. For the past 15 years or more, they have not understood this. That is why we have a rate of almost 20% of newly diagnosed men with metastatic cancer; and why prostate cancer diagnoses are rising at 16% per annum vs 3% per annum for breast cancer. Men don't get tested. Not to mention, there are many treatments today to keep men over 70 alive."
Davis, himself a PCa survivor, added: “They should direct their attention to teaching the urologists and rad oncs the difference between information and treatment and that not every man with PCa needs active treatment. At the root of this is a financial conflict of interest. Overtreatment is rarely associated with Centers of Excellence.
On to the new research.
In a group of over 30,000 men, recent PSA screening rates were 55.3% for men ages 70 to 74, 52.1% for those ages 75 to 79, and 39.4% for those ages 80 and older, reported Sandhya Kalavacherla, BS, of the University of California San Diego School of Medicine in La Jolla, and colleagues in JAMA Network Open
(The New York Times just reported on this study.)
Discussing PSA testing advantages with a clinician was associated with increased recent screening, while discussing PSA testing disadvantages had no association with screening.
Researchers said this suggests "that any discussion of PSA testing likely occurs in the context of a clinician- or patient-initiated effort to ultimately screen for prostate cancer.”
Among all racial groups, non-Hispanic White males had the highest screening rate (50.7%), and non-Hispanic American Indian males had the lowest screening rate (32.0%). Screening increased with higher educational levels and higher income.
Married respondents were screened more often than unmarried males. Discussion of PSA testing advantages with a clinician was associated with increased recent screening, whereas discussing PSA testing disadvantages had no association with screening.
Other factors associated with a higher screening rate included having a primary care physician, a post–high school educational level, and an income of more than $25 000 per year.
Researchers from the Centers for Disease Control and Prevention, reported last year that test intensity in men 70 years and above has decreased but is higher than in men aged 55 to 69 years. “The proportion of men aged ≥70 years who reported 4 to 5 PSA tests in the last 5 years decreased from 37.2% in 2010 to 31.1% in 2018, while the proportion reporting 1 to 3 PSA tests increased from 25.5% to 31.9%.” CDC said that in 2018, In 2018,the intensity of PSA testing in the previous 5 years was significantly higher among men aged 70 to 79 years than among men aged 55 to 69 years,
Meanwhile, researchers at Wake Forest University School of Medicine, Winston-Salem, North Carolina, noted that PSA testing and DRE exams are not recommended for men over 70.
They said such screening can result in false positives that potentially can take these patients down the rabbit hole of overdiagnosis and overtreatment, with risks for adverse effects from unnecessary, aggressive treatment.
“As a man ages, the risk for a false-positive result increases,” said lead author Chris Gillette, PhD, associate professor of physician assistant studies at Wake Forest. “Men who are 70 years and older are at the highest risk for overdiagnosis.”
This study appears in the Journal of the American Board of Family Medicine.
Gillette and colleagues conducted a secondary analysis of the National Ambulatory Medicare Care Survey datasets from 2013-2016 and 2018. The dataset is a nationally representative sample of visits to non-federal office-based physician clinics.
Previous studies have relied on commercially insured men or patient-reported rates of PSA testing. The Wake Forest researchers used a more inclusive nationally representative clinical dataset, with men who are also uninsured or insured through traditional Medicare.
In looking at primary care visits for men over the age of 70, the researchers found 6.71 PSA tests and 1.65 DREs per 100 visits.
Gillette noted the researchers restricted their analysis to primary care providers and those patients without any clear medical history that would necessitate a PSA or DRE as a diagnostic test.
Is your primary care physician test-happy?
Gillette said, “We also found that providers who order a lot of tests are more likely to order low-value screening such as PSA and DRE.”
Specifically, for each service ordered, there was a 49% increase in the odds of a low-value PSA and a 37% increase in the odds of a low-value DRE.
Kevin Ginsburg, MD, director of the prostate program at the Michigan Urological Surgery Improvement Collaborative (MUSIC), said the guidelines emphasize NOT screening men over 70 who have not been diagnosed with prostate cancer. “That being said, a lot of the guidelines give some wiggle room that if men maintain excellent health after the age of 70 with a long life expectancy, continued PSA screening may still be reasonable,” said the urologic oncologist from Wayne State University in Detroit.
PSA testing has been steeped in controversy since it was introduced in the 1990s.
In 2008, the U.S. Preventive Services Task Force, a non-governmental agency that develops guidelines for primary care physicians, recommended against PSA testing in men aged 75 and above.
The group has made several revisions, resulting in PSA becoming a moving target and a political football.
The USPSTF’s 2018 prostate cancer screening guidelines recommend against providing men 70 years and older with PSA screening.
USPSTF Recommendation Summary
Men aged 55 to 69 years
For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one. Before deciding whether to be screened, men should have an opportunity to discuss the potential benefits and harms of screening with their clinician and to incorporate their values and preferences in the decision. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs. Clinicians should not screen men who do not express a preference for screening. Grade: C (C is the lowest grade for a guideline.)
Men 70 years and older
The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older. Grade: D (D means not recommended).
PSA screening has declined since 2014, which has infuriated some advocates and urologists and left primary-care doctors, who order most PSA tests, frustrated and confused.
Gillette speculated that healthcare professionals might be responding to patient requests when ordering these screening tests or using what's known as a “shotgun” approach to medical testing, where all possible tests are ordered during a medical visit.
"However, as healthcare systems move toward a more value-based care system — where the benefit of services provided outweighs any risks — clinicians need to engage patients in these discussions on the complexity of this testing," he said. "Ultimately, when and if to screen is a decision best left between a provider and the patient.
If you are over 70 and haven’t already been diagnosed with prostate cancer, be sure to discuss with your primary care doctor whether PSA screening makes sense for you. If you’re over 70 and on AS, ask what your urologist suggests for you moving forward.
What about the over 70s and 80s who have been diagnosed with lower-risk PCa?
By Howard Wolinsky
The debate about PSAs past 70 is aimed at men who have not been diagnosed with prostate cancer. What about us?
Age is a key factor your doctor considers in recommending AS. If your “time horizon” is long, chances are the urologist—doing an “eyeball” exam (an overall look at you) and also running an algorithm including your vital stats—will determine your odds for good health and AS-worthiness in the coming decade.
PSA testing is a routine part of monitoring, no matter the age, in men of all ages who are healthy otherwise and opt for Active Surveillance.
I’m 75 and am following a middle path between AS and WW. I have not had routine MRI scans and biopsies in since 2017. I just undergo PSA testing annually. (My results are just in—everything “stable” and teed up for another year of AS.)
This is doctor-approved personalized care. And I have my own name for it: passive-aggressive surveillance. Not quite AS; not quite WW.
What about those 80 and above who have been diagnosed with PCa?
Here’s what two patients with low-risk prostate cancer think:
Howard Furer hopes to be on AS when he’s in his 90s.
He told me: “Not much has changed since last year. I still get a PSA test every six months. The last one in January was 3.4. I continue to be active physically – – Hiking, swimming, biking, weightlifting, yoga.
“I recently added a new activity of ping-pong once a week. I will be 84 years old in August. I have BPH, typically waking up twice each night to pee, but go right back to sleep. I continue to focus on a mostly plant-based and fish diet with emphasis on high nutrient-density foods. I continue to take Dutasteride as my prostate medication.”
Allan Greenberg keeps debating whether he should stay on AS in his 80s.
Here’s his update: “Things are a bit topsy-turvy in my world at this time. Insofar as PCa is concerned: for the time being, at 82, I am continuing my twice yearly PSA. I am maintaining a vegetarian-tending diet, with fish and occasional chicken--no red meat; I continue with tai chi, square and round dancing, hiking, and birding--EXCEPT at present we are preparing to move to Vermont [from near Boston] and our time is almost entirely devoted to preparing our house for a renter and moving half of our possessions north, and this for me has interfered with almost everything else (other than being appalled by some of what is going on today with the challenges to libraries and schools, etc.).”
Where do you stand?
Dr. Jonathan Epstein’s video and Q&A
By Howard Wolinsky
Jonathan Epstein, MD, of Johns Hopkins, is an international pathology rockstar.
He drew about 650 registrants to his April 29 videos from Active Surveillance Patients International’s event. Many just wanted to view the videos later. More than 250 patients attended the meeting.
So ASPI’s Bill Manning posted the videos STAT.
Here is the video from Active Surveillance 101 in biopsies and second opinions along with a Q&A with Dr. E.: https://aspatients.org/meeting/as-101-episode-5-second-opinions-and-biopsies/
The ActiveSurveillor.com will report more soon.
The full AS 101 series is available at https://aspatients.org/meeting/second-opinions-and-biopsies/