A 72 year old client asked me if he should get a screening PSA test.  The answer – it depends… Screening for cancer with the PSA (Prostate Specific Antigen) test is a controversial topic. On the plus side of doing a PSA, a cancer may be detected earlier.  On the minus side, what do you do if there is a positive or equivocal result – especially in men over 70?

Most prostate cancers grow slowly – taking years until they cause any trouble.  But in 10 to 15 percent of cases, the cancer grows aggressively.

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Are you a candidate for prostate screening?

If you find cancer, do you treat it?  A study looked at whether or not there is any advantage to treating early.  The Prostate Intervention Versus Observation Trial (PIVOT) evaluated no treatment versus performing a radical prostatectomy and found no difference in mortality.  The follow-up has been approximately 12 years – more follow-up is needed.

Who should be screened?

There are several differing opinions from medical organizations.  The US Preventive Services Task Force does not recommend any form of screening.-

The American Cancer Society suggests informing patients of the risks and benefits of screening. If the man’s life expectancy is less than 10 years, they would recommend against screening.   But, if there is a strong family history of prostate cancer in a first degree relative many would screen starting at age 40- 45.   If the PSA level is less than 2.5 ng/mL, retesting is suggested at 2 year intervals.  For higher PSA levels – test annually.

The National Comprehensive Cancer Network revised their guidelines in 2014.  They recommend a baseline PSA test at age 45-49; if levels are 1.0 ng/ml or greater, annual or biannual testing is recommended.  For ages 50-70 with a PSA below 3 ng/mL, the recommendation is retesting every 1-2 years.

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The blue splotches, T1 through T3 illustrate the stages of prostate cancer.

The following guidelines are from the American Urological Association (AUA) and the American College of Physicians (ACP).

The AUA urology group does not recommend testing for:

  • Men 40 years of age or younger
  • Men 40 to 54 years old who are at average risk
  • Men 70 years of age or older
  • Men with a life expectancy of less than 10 – 15 years

The ACP advises no screening for:

  • Men who do not express a preference for screening
  • Men under 50 with average risk
  • Men over 69
  • Men with a life expectancy of less than 10-15 years

Faced with these conflicting opinions by thought leaders in medicine, what should be recommended to the 72 year old patient?  It is unclear.  A patient physician discussion should include that that most physicians would not screen at his age.

But what if the patient counters with a family history of longevity and that he might die earlier from undiscovered aggressive prostate cancer?

This is a frustrating situation for patient and physician.  Unfortunately, in medicine and life we frequently have to cope with uncertainty.

Photos courtesy of Wikimedia and Eileen Hilton.

Dr. Hilton is the President and CEO of Crown Care Hawaii, a local company providing patient advocacy and Medicare navigation services. Before starting Crown Care, Dr. Hilton was in clinical practice as an internist with a subspecialty of infectious disease. She is Professor of Clinical Medicine Emerita at the Albert Einstein School of Medicine and has published numerous peer-reviewed articles and books.

 

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