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PSA Screening in Older Men

Many elders, especially those with limited life expectancies, are inappropriately undergoing PSA screening.

Despite lack of definitive evidence that prostate cancer screening lowers the rate of prostate cancer–specific mortality, some major U.S. health organizations, such as the American Urological Association and the American Cancer Society, recommend annual prostate-specific antigen (PSA) screening for men who are 50 or older with at least a 10-year life expectancy. Other groups, including the U.S. Department of Veterans Affairs (VA), have taken the position that insufficient evidence exists to support routine screening. Notwithstanding this disagreement about routine screening for healthy men older than 50, all agree that screening of men with short life expectancies confers possible immediate harm without providing meaningful future benefit.

In a cohort study that involved approximately 600,000 male U.S. veterans (age, 70; median age, 77) without diagnoses of prostate cancer, elevated PSA levels, or symptoms of prostate cancer, investigators characterized the extent of PSA screening among older men, including those with life expectancies shorter than 10 years. Data from calendar year 2003 were retrieved from 104 VA facilities, and linked Medicare information was obtained for patients who received additional services outside the VA system. Charlson Comorbidity Index scores were used to stratify men into three groups (best health to worst health). To confirm that most PSA assessments were for screening purposes, the researchers randomly audited 100 charts in the San Francisco VA system; 87% of PSA tests were performed to screen asymptomatic men.

Thirty percent of the cohort had Charlson scores of 0 (best health), and 15% had Charlson scores of 4 (worst health). PSA testing had been performed on 56% of the cohort. Age was the strongest predictor of PSA screening. Although the rate of PSA screening did decline with advancing age, the disparity between the percentage of screened men and the percentage of men expected to survive for at least 10 years was greatest in the oldest age group; thus, a disproportionate number of older men in worse health were screened. Among the oldest men (age, 85), 34% in the best-health category and 36% in the worst-health category were screened.

Comment: In the U.S., prostate cancer screening is ubiquitous, despite the lack of prospective data on mortality benefit. Two large screening studies are underway that might provide the needed data, but final results will not be available until early in the next decade. The results of the current study demonstrate that many elders, especially those with limited life expectancies, are inappropriately undergoing PSA screening.

— Robert Dreicer, MD, MS, FACP

Published in Journal Watch Oncology and Hematology November 14, 2006

Citation(s):

Walter LC et al. PSA screening among elderly men with limited life expectancies. JAMA 2006 Nov 15; 296:2336-42.

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