Posted 5/7/2017 12:55 PM (GMT -5)
In reviewing the controversy of PSA testing, I was intrigued by that part of the report which discussed recommendations for men age 70 and older. I’m 71 now and wonder what if anything this discussion means to me. From the American Urology Association:
The Panel recognizes that men age 70+ years can have a life-expectancy over 10 to 15 years , and that a small subgroup of men age 70+ years who are in excellent health may benefit from PSA screening, but evidence to support the magnitude of benefit in this age group is extremely limited. Men in this age group who choose to be screened should recognize that there is strong evidence that the ratio of harm to benefit increases with age and that the likelihood of overdiagnosis is extremely high particularly among men with low-risk disease.
Evidence for screening benefit in this setting is unclear and indirect. An absolute reduction in mortality is possible but likely small with a quality rating of C. The quality of the evidence for harm remains high or at least higher than benefit (A). The certainty in the balance of harm and benefit is moderate justifying a recommendation against routine PSA-based screening.
The rationale for this recommendation is based on the absence of evidence of a screening benefit in this population with clear evidence of harms. In the ERSPC randomized trial of screening, there was no reduction in mortality among men age 70 years or older.17 Although men in this age group have a higher prevalence of prostate cancer and a higher incidence of fatal tumors, they also have increased competing mortality compared to younger men,94 and no compelling evidence of a treatment benefit, especially in men with a limited life expectancy below 10 to 15 years.95,96Therefore, given the lack of direct evidence for benefit of screening beyond age 70 years, and especially beyond age 74 years, as well as higher quality data regarding harms, the Panel discourages routine screening in this age group.
Men age 70+ years who wish to be screened should do so after an understanding that the ratio of benefit to harm declines with age, although there is evidence that men with high risk disease in this age range may benefit from early diagnosis and treatment over a decade or less.96 In order to identify the older man more likely to benefit from treatment if screening takes place, the Panel recommends two approaches. First, increasing the prostate biopsy threshold based on evidence that men with a PSA level above 10ng/ml are more likely to benefit from treatment of prostate cancer when compared to those with a PSA below 10ng/ml.96 Second, discontinuation of PSA screening among men with a PSA below 3ng/ml, given evidence that these men have a significantly lower likelihood of being diagnosed with a lethal prostate cancer during the remaining years of life when compared to men with a PSA above 3ng/ml.97
The likelihood of overdiagnosis increases as men age, and is particularly high for older men with low-risk disease. Modeling studies of overdiagnosis in the US population have estimated that among men aged 70 to 79 years, half or more of cases detected by PSA screening with PSA less than 10 and Gleason score 6 or below are overdiagnosed. Among men over age 80 years, three-fourths or more of cases detected by PSA screening with PSA less than 10 and Gleason score 6 or below are overdiagnosed.109 Because of the harms of biopsy, overtreatment, and overdiagnosis in this population, shared decision making and consideration of individual values, preferences, and quality of life goals are paramount.