Louise C. Walter, MD -----
A study of almost 600,000 men aged 70 and older reveals that 56 percent had a routine prostate-specific antigen (PSA) screening, a blood test for prostate cancer, even though no treatment guidelines recommend PSA screening for men of that age.
Screening rates declined with age, but overall health had little or no impact on whether a PSA test was performed.
In fact, says lead author Louise C. Walter, MD, a staff physician at the San Francisco VA Medical Center, health status had so little bearing on the decision to screen that 36 percent of men age 85 and older who were in poor health and at high risk of dying within a year were given the test.
“Not a single professional organization, physicians’ group, or prostate cancer advocacy group advocates PSA screening for frail, elderly men, and yet we are doing it,” says Walter, who is also an assistant professor of medicine at the University of California, San Francisco.
The study appears in the November 15, 2006 issue of the Journal of the American Medical Association.
In general, performing the PSA test on men 70 and older is a poor idea for a number of reasons, Walter says. “First, as you grow older, there’s good evidence that PSA becomes less accurate. Second, not all prostate cancers are alike.” The PSA test is best at detecting slow-growing cancers that will have a health impact 10 to 15 years after they are found, Walter explains, while it tends to miss aggressive, fast-growing cancers. “Third, it’s been well-documented that older men, particularly those with chronic or severe illnesses, have more complications from all types of prostate cancer treatment than younger men.” Finally, says Walter, even if no treatment is performed, simply the knowledge of an elevated PSA causes anxiety and thus has a negative impact on quality of life.
“This is why no guideline recommends PSA screening for men who, taking health status as well as age into account, have a life expectancy of 10 years or less,” concludes Walter.
The study authors examined the medical records of 597,642 men seen at 104 VA facilities during 2002 and 2003. They excluded men with prostate symptoms, a history of prostate cancer, or any other medical condition that indicated a need for the test.
The researchers classified the men into four age categories (70-74, 75-79, 80-84, and 85-plus) and three health categories (best, average, and worst) based on the Charlson co-morbidity index, a standard measure of risk of death. The men in the “worst” category were four times more likely to die within one year than men in the “best” category.
Age was the strongest predictor of PSA screening: 64 percent of all men aged 70 to 74 had the test, while 36 percent of all men 85 and older had it. Health status was only a mild predictor: 58 percent of the men in best health were tested versus 51 percent of the men in worst health.
Within each age range, health status made so little difference in who got screened that among men age 85 and older, 36 percent of men in the worst health were screened while only 34 percent of men in the best health were screened. “For these elderly men in very bad health, the PSA test is more of a disservice than it is a help,” says Walter. “In fact, it actively takes away from time we should spend helping them with their immediate health problems.”
A number of non-clinical factors had greater influence than health status on determining screening, she says. Southerners were more likely to be tested than men in other regions of the country. Married men were more likely to be tested than single men. The higher the income a man had, the more likely he was to be tested. Paradoxically, African-Americans were less likely to be tested, “even though African-Americans are at higher risk for prostate cancer and prostate cancer mortality,” says Walter.
The study did not examine the reasons for the high rate of inappropriate testing, or for the influence of non-clinical factors on testing. Walter says that current publicity campaigns urging all men to get screened provide inappropriate, overly simplistic advice. “We need to educate the public more about the downsides of screening tests. As you grow older and develop more and more chronic or severe diseases, those are the things you and your doctor should focus on. This isn’t about cost-cutting. It’s about not doing harm by not subjecting people to tests and procedures they don’t need.”
Co-authors of the study were Daniel Bertenthal, MPH, of SFVAMC; Karla Lindquist, MS, of SFVAMC and UCSF; and Badrinath R. Konety, MD, of UCSF.
The study was funded by grants from the Department of Veterans Affairs.
SFVAMC has the largest medical research program in the national VA system, with more than 200 research scientists, all of whom are faculty members at UCSF.
UCSF is a leading university that advances health worldwide by conducting advanced biomedical research, educating graduate students in the life sciences and health professions, and providing complex patient care.