The prostate-specific antigen (PSA) test is commonly used to screen for prostate cancer in men. The test measures the level of PSA, a protein produced by the prostate, in the blood. As men get older, their risk of prostate cancer increases. However, there is considerable debate around PSA screening in older men. Current guidelines do not recommend routine PSA screening in men over 70 years or any man with less than a 10-15 year life expectancy. There are several reasons why PSA testing is controversial and often not advised in older men.
Low Risk of Dying from Prostate Cancer
While prostate cancer is common, most cases are slow-growing and unlikely to cause death. Autopsy studies show that many older men who died from other causes also had prostate cancer that never affected them during life. According to the National Cancer Institute, only about 3% of men die from prostate cancer. This risk is even lower in older men as shown in the table below:
| Age Group | Risk of Dying from Prostate Cancer |
|---|---|
| 50-59 years | 0.4% |
| 60-69 years | 1.2% |
| 70-79 years | 2.2% |
As the data shows, even though the risk of prostate cancer mortality increases as men get older, it is still relatively low. For most men over 70, the risk of dying from prostate cancer is less than 3%.
PSA Screening Leads to Overdiagnosis
A major downside of PSA testing is overdiagnosis – detecting small, slow-growing prostate tumors that were unlikely to cause harm during a man’s lifetime. Autopsy studies again show that about 30-50% of men in their 60s, and up to 80% of men in their 70s had prostate cancer – yet most of these men died from unrelated causes. Most of these cancers were small, low-grade tumors that likely would not have led to symptoms. Yet if discovered through screening, this can lead to unnecessary stress and treatment.
Overdiagnosis is considered one of the biggest risks of PSA testing. Older men are at higher risk of overdiagnosis because they have a higher chance of having indolent cancers. Subjecting them to screening may turn up small tumors that would be better left undetected and untreated.
High Risk of False Positives
Many things besides cancer can elevate PSA levels, such as benign prostatic hyperplasia (BPH) and prostatitis. Older men frequently have enlarged prostates causing higher PSA results. This leads to a relatively high false positive rate with PSA testing in this population.
According to some estimates, about 75% of positive PSA tests in men over 70 are false positives. This means 3 out of 4 men with a high PSA level do not actually have prostate cancer. False positives lead to unnecessary biopsies and worry. Given the low risk of clinically significant prostate cancer in older men, the harm of false positives generally outweighs the benefits of screening.
Potential Harms of Biopsy
If PSA screening indicates possible cancer, the next step is a prostate biopsy to confirm diagnosis. This involves using thin needles to take samples of prostate tissue. While considered a safe procedure, prostate biopsy carries significant risks including:
- Pain and discomfort
- Urinary difficulties
- Bleeding
- Infection which may require hospitalization in about 2-4% of men
Complications are more common in older patients who are generally more frail. Subjecting men over 70 to biopsy when most have benign conditions or non-threatening cancers has questionable benefit.
Side Effects of Treatment
The purpose of early detection is to find prostate cancer when it is still curable. However, studies show that the PSA test has not reduced deaths from prostate cancer. While it has led to more cancers being diagnosed at an early stage, there is debate whether this actually saves lives. Treatments for prostate cancer also carry significant side effects.
Some common treatments and potential side effects are summarized below:
| Treatment | Common Side Effects |
|---|---|
| Surgery to remove prostate (radical prostatectomy) | Urinary incontinence, erectile dysfunction |
| Radiation | Bowel, urinary and sexual dysfunction |
| Hormone therapy | Hot flashes, weight gain, erectile dysfunction, loss of bone and muscle mass |
These side effects may be more challenging for older men to deal with. Those diagnosed at an older age are also more likely to receive hormone therapy rather than surgery or radiation.
Quality of Life Impact
For older patients with a limited life expectancy, the impact of cancer treatment on quality of life is an important consideration. Side effects like incontinence and impotence can significantly reduce an older man’s independence and well-being. The risks of screening and treatment may outweigh any potential survival benefit.
Risk of Complications from Treatment
Surgery, radiation and other treatments also have higher complication rates in older patients who have more comorbidities. Up to 1 in 5 men over age 70 experience serious complications after radical prostatectomy. Risks include:
- Heart attack
- Stroke
- Deep vein thrombosis
- Pulmonary embolism
- Poor wound healing
- Infections
- Loss of urinary and sexual function
Research shows higher rates of hospitalization, transfusions, and other adverse events in older men treated for prostate cancer. The benefits of finding an early cancer that may never cause harm must be carefully weighed against treatment risks.
Limited Life Expectancy
PSA screening aims to detect prostate cancer before symptoms develop. However, it may take 10-15 years from diagnosis for prostate cancer to progress and become life-threatening. The goal is to find cancer before it spreads outside the prostate gland, when it is easier to cure.
Men over 70 often have a limited life expectancy due to age or health conditions. Other diseases like heart disease and lung disease are much more likely to cause death. The table below shows the average remaining life expectancy based on a man’s current age:
| Age | Average Years of Life Remaining |
|---|---|
| 70 | 12.7 years |
| 75 | 10 years |
| 80 | 8.1 years |
| 85 | 6.1 years |
There is little benefit to finding a cancer at 70-80 years if the patient is unlikely to survive 10+ more years when the cancer may become aggressive. The PSA test cannot differentiate aggressive vs. indolent cancers either.
Aligns with Other Guidelines
The decision to stop screening aligns with guidelines for breast and colon cancer screening which also do not recommend continuing past a certain age or life expectancy. Prostate cancer screening should similarly be individualized based on a man’s overall health.
Patient Anxiety and Stress
Undergoing screening and being diagnosed with cancer, even if slow-growing, is understandably anxiety provoking for patients. Older patients may experience loss of sleep, appetite changes, sadness and other distress. Frequent testing also increases worry about cancer.
One study found that prostate biopsy after an abnormal PSA caused higher anxiety levels in 78% of men. Men who had a false positive result experienced more anxiety and distress at 1 month than those with confirmed cancer. Unnecessary cancer scares should be avoided in older men.
Costs of Testing and Follow-up
Routine PSA testing in older men also carries financial costs. These include:
- Cost of PSA test every 1-2 years
- Urology consult for abnormal results
- Prostate biopsy
- Additional scans and consults if cancer is suspected
- Treatment costs for those diagnosed with cancer
Estimated costs for just the initial diagnostic workup range from $1200 to over $4000 per patient. Costs rise further with treatment or if complications develop. With limited benefits, spending healthcare dollars on screening older men may not be the best use of resources.
Shared Decision Making
The decision about PSA screening for any man, especially those over 70, should be individualized as the benefits vs harms are closely balanced. Guidelines recommend that physicians have an open discussion with patients to inform them on the pros and cons of testing before deciding.
Some questions doctors may ask patients include:
- What is your general health status and life expectancy?
- How concerned are you about prostate cancer?
- What types of side effects or complications concern you most if prostate cancer was found and treated?
- Would knowing you have prostate cancer, even if slow-growing, distress you?
Patients must evaluate their personal situation, preferences and values before getting screened. Doctors can advise patients based on their individual risk factors while respecting patient autonomy in decision-making.
Informed Decision Making
The American Cancer Society and American Urological Association recommend an informed decision making process for men considering PSA testing. This involves:
- The physician explaining details about the PSA test
- Discussion of potential benefits and harms
- Consideration of the patient’s general health, life expectancy and personal preferences
- A shared decision between the patient and physician on whether to get tested
Doctors should avoid routine screening without this discussion. Men should consider their individual circumstances rather than taking a one-size-fits-all approach to PSA testing after age 70.
Conclusion
In conclusion, PSA testing is controversial in older men due to risks of overdiagnosis, complications and limited life expectancy. While prostate cancer is common, most cases are slow-growing and unlikely to impact survival. On the other hand, the screening process and cancer treatment can significantly reduce quality of life for older patients. Guidelines agree that men over 70 should not have routine PSA screening. Instead, doctors should engage in shared decision making with patients. Older men in good health who may live over 10-15 more years may still potentially benefit. However, many men over 70 are likely to be harmed rather than helped by prostate cancer screening. Doctors must assess each patient’s individual situation, preferences and values when advising on PSA testing.