This week’s article in the Annals of Internal Medicine about the benefits and risks of screening for prostate cancer is certainly going to fuel the debate about whether or not men younger that the age of 75 should be routinely screened for this disease.
However, for men 75 and over, according to the government experts, the question has been answered: don’t bother.
But is that the best answer for you?
For those of you approaching the age of 75, those may be viewed as “fighting words.” You may be getting older, but probably believe you are getting better at enjoying your life. So why not do everything you can to make certain that the years you have on this earth will be time spent free of prostate cancer and its consequences?
The experts have reviewed the scientific evidence, and the jury has returned the verdict. They say the conclusion is clear that for men age 75 and over, screening for prostate cancer with the PSA test doesn’t offer much benefit, and it certainly can cause harm. So, don’t do it.
Back when I was a medical student, we were taught that almost all men who were autopsied at age 90 had evidence of prostate cancer, no matter what they died from. It was clear that although prostate cancer was a serious and fatal disease for some men, it wasn’t life threatening for many, many more.
When we began using the PSA test in the late 1980’s, we started finding a lot of prostate cancer. But we still don’t know the answer to the question as to whether or not we are really doing any good by ordering this simple blood test.
There are experts who say the PSA test saves lives. There are other experts who don’t think screening saves lives. We have experts who say our threshold for normal on the PSA test is too high, and others who say lowering it would result in many more unnecessary and harmful biopsies and treatments.
Enter the United States Preventive Services Task Force, an authoritative group run under the auspices of the Department of Health and Human Services. This is the group that is highly regarded for its thorough reviews of medical evidence and recommendations for common medical treatments.
Like many other organizations—including the American Cancer Society—the USPSTF has been burdened by a lack of good evidence-based studies to tell us whether or not prostate cancer screening really does save lives.
Yes, we all know someone who was 52 or 53 years old who had a PSA test that was abnormal and was found to have prostate cancer. Everyone thinks the test saved his life.
But we don’t talk about all the men who are incontinent of urine, can’t have sex, or even died as a result of the treatment for a cancer that may never have caused a problem during their lifetime. Those stories somehow don’t get told.
The truth is that we don’t know which prostate cancers are really bad and which ones wouldn’t make a difference in our lives if we left them alone.
Against this backdrop, and against the backdrop of a significant amount of public opinion and advocacy that supports prostate cancer screening, the USPSTF recommendation that clearly state that PSA testing for men age 75 and over shouldn’t be done took a lot of courage. It is also certain to generate a lot of backlash and criticism.
The American Cancer Society has indicated that, given its own current review of our prostate cancer screening guideline, it is not appropriate for us to comment for or against the USPSTF recommendations.
In reality, the guidelines of both organizations are very similar, except for the new 75 and over exclusion.
We do recommend that the test be offered to all men at average risk age 50. The key word here is “offered”. That isn’t a recommendation to do the test.
That phrasing has given a lot of people pause in terms of what it means. It means that a doctor should offer—not recommend--the test while discussing the risks and benefits of prostate cancer screening with the patient. If the patient says, “Doc, you decide what I should do,” then the PSA test should be done according to our current recommendations.
For African-American men, who are at a higher risk of death from prostate cancer than white men, we recommend the test should be done beginning at age 45. That is not the same as offering the test. The same is true for any man with a first degree relative who has had prostate cancer. And for men with more than one first degree relative with prostate cancer, they can consider testing beginning at age 40.
Yes, I know that all of this is very confusing. If you need help and guidance, you can go to our website at www.cancer.org, or call our cancer information service at 800-ACS-2345 and an information specialist will help you sort out the recommendation for you based on our current guidelines.
But age 75 and over? We still make the same recommendation we have for several years: be informed and make a choice on what you want to do.
However, you should also know that no matter what your age, if your life expectancy is 10 years or less, then we do not recommend you get screened for prostate cancer. That is because for most men, even those with undiagnosed prostate cancer, their other medical illness will cause their death.
I still think the 75 year old situation is a difficult one.
75 today isn’t 75 a couple of decades ago. There are many active 75 year old men who—although they may have some chronic illnesses such as high blood pressure or cholesterol—will certainly live beyond 85.
What makes this analysis so difficult is that many of those men—even those with normal PSAs—can harbor prostate cancer in their prostate glands. If you go looking hard for prostate cancer in an older man, there is a reasonable chance you will find it. But then the question is “so what?”
If that prostate cancer is indolent, meaning it doesn’t grow fast and won’t cause a problem, then the mere diagnosis and biopsy procedures to confirm the diagnosis can be a problem. And, if you elect to treat it, you may be left incontinent, dribbling urine, or have other difficulties which could make life very uncomfortable.
And then there is the issue that no one wants to talk about: what if the treatment killed you? It does happen, but no one emphasizes that point. If you have an indolent cancer diagnosed, elect to be treated, and die as a result, then you may have lost many years of enjoyable life. There was a phrase ingrained in me early in my medical career, and it sticks with me now: First, do no harm.
What the USPSTF found, and why they made their recommendation, was that the available evidence did suggest that the harms of PSA testing in men age 75 and over outweighed the benefits, and therefore the test shouldn’t be done.
As noted in the task force report, these are guidelines, not absolute recommendations. It is still up to you and your doctor and your family what you want to do when it comes to PSA testing, whether you are younger or older than 75.
So we are still left with the sad reality that there is much we don’t know about the diagnosis and treatment of this very common cancer.
“Informed decision making”—weighing the benefits and risks of a particular medical procedure or intervention—is really a euphemism for “we aren’t certain what to do in this situation.” That leaves it up to each of us to make our decisions. That my friends is what we call a “conundrum.”
The Task Force has whittled down that conundrum a bit, although many people won’t agree with them.
In the meantime, get engaged and get informed. It’s your health, and your responsibility to make the decision on what you want to do. At least if you are between the ages of 50 and 74.
If you are 75 or older, the Task Force may have made the decision for you. But ultimately even that decision is yours to make.