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Screening the Elderly and the Very Ill Can Do More Harm Than Good
Many elderly men are getting screened for prostate cancer unnecessarily, according to researchers from the San Francisco VA Medical Center.
In a study of nearly 600,000 men aged 70 and older who had been seen at dozens of VA hospitals across the United States, the research team found high rates of inappropriate PSA testing, even among men with multiple illnesses who were unlikely to survive more than 10 years.
The older a man is, the more likely he is to develop prostate cancer. At the same time, however, the older the man, the more likely he is to die of something else before the prostate cancer can even begin to cause symptoms.
And while the cancer itself might never cause symptoms, the treatment for it may. Treatments for prostate cancer can lead to serious side effects like incontinence, impotence, and bowel function problems, which can severely reduce quality of life. That's one reason no national organization recommends prostate cancer screening for men with a life expectancy of less than 10 years.
The American Cancer Society recommends doctors discuss the risks and benefits of yearly screening beginning at age 50 (or younger for men at high risk of the disease) with men who have at least a 10-year life expectancy.
The study findings suggest many men are being subjected to unnecessary anxiety about test results and a cancer diagnosis, unneeded diagnostic procedures, and potential side effects of prostate cancer treatment, says lead researcher Louise C. Walter, MD, a staff physician at the San Francisco VA Medical Center and assistant professor of medicine at the University of California, San Francisco.
"I've seen it happen to my patients," explains Walter a geriatrician. "They get very worried and get procedures done to them that leave them incontinent and impotent for a disease that I thought wasn't going to cause them major problems."
Other experts agree the findings are cause for concern. Several studies suggest that men over 70 or 75 can indeed suffer because of the procedures used to diagnose and treat prostate cancer, notes Andrew Wolf, MD, assistant professor of medicine at the University of Virginia Health System and a member of the ACS Primary Care Advisory Committee.
"There's a good chance a lot of these men are being harmed," adds Wolf, who was not involved in the study.
Overall, 56% of the men in the study group had PSA testing done during the year, although none of them had a history of prostate cancer, elevated PSA, or symptoms of the disease that would give a medical reason for such testing. PSA screening rates did go down with age, but not as much as the researchers expected.
And the decline in screening did not necessarily correspond to worsening health. Among men 85 and older, for instance, 34% of those in "best health" (those with the fewest other illnesses or limitations) got PSA tests, compared to 36% of those in "worst health." The study did not examine how many of the men may have requested the test, as opposed to their doctor just ordering it for them.
The results were published in the Journal of the American Medical Association.
Overzealous screening can steal valuable time from more pressing medical concerns such as dementia, congestive heart failure, dialysis, oxygen dependency, and functional limitations, Walter notes.
"You put any of those [conditions] with [age] 85 and above and you do wonder why you'd be getting a PSA test," she says.
Better guidance for estimating a man's life expectancy could help doctors avoid unnecessary prostate cancer screening, she adds.
Physicians need to have frank discussions with their elderly male patients about the pros and cons of prostate cancer screening, Walter and Wolf agree.
"I simply explain to them that prostate cancer is one of those areas where oftentimes in the elderly the cure is worse than the disease," Wolf says. "While it's only a blood test or rectal exam or both, it leads rapidly to other testing and interventions that have serious downstream effects -- like death, incontinence, or complications from surgery and radiation -- that, being older, they're much more susceptible to."
Some men will choose to be screened regardless of the risks, Walter acknowledges. But when that happens, "I do make sure they understand that there are downsides and that it's not just a blood test," she says.
Citation: "PSA Screening Among Elderly Men With Limited Life Expectancies." Published in the Nov. 15, 2006, Journal of the American Medical Association (Vol. 296, No. 19: 2336-2342). First author: Louise C. Walter, MD, San Francisco VA Medical Center.
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