Are Men Older Than 70 Subjected to Too Much Prostate Cancer Screening?
Today, most older men have almost certainly know about the importance of prostate cancer screening. Guys in their 20s and 30s are taught about testicular cancer awareness. Similarly, men in their 40s and 50s know about prostate cancer screening recommendations.
According to the American Urological Association (AUA), clinicians should begin offering screening for elevated prostate-specific antigen (PSA) levels for men of average risk between ages 45 and 50. Screening should first be offered between ages 40 and 45 for men with higher risk factors. Those risk factors include the following:
- African-American ancestry
- Germline mutations
- A strong family history of prostate cancer
After age 69, men not be routinely screened and clinicians shouldn't recommend it.
That screening advice only holds true for a finite period, though. AUA guidelines and the U.S. Preventive Services Task Force (USPSTF) 2018 guidelines are in agreement. They recommend that, after age 69, men not be routinely screened and clinicians shouldn't recommend it.
Despite that, a new study shows many older men are still being routinely screened.
If screening is so valuable (it is) why do these associations recommend against screening older men? Why are so many men in their 70s still being screened? The real-world application of these recommendations may be trickier than it appears on paper.
The recommendations for prostate cancer screening
Both the AUA and the USPSTF base their screening recommendations on a cost-benefit analysis.
"Both are in agreement: There isn't much benefit in detecting slow-growing cancer like prostate cancer in men who are most likely not going to die from it," said Neel Parekh, M.D., a men's fertility and sexual health specialist with Cleveland Clinic.
While the AUA and USPSTF know it's possible to detect new prostate cancer in a man older than 70, but the likelihood is that he will die with it and not from it. The AUA's and USPSTF's thinking means routine testing is not only pointless but potentially harmful.
"The risk is, if you detect cancer, it can lead to unnecessary procedures like biopsies, which have a risk of complications," Parekh said. "And, of course, treatment of prostate cancer has the risk of complications: urinary incontinence, erectile dysfunction—those are the main things. So you find something that may never have been an issue. And a lot of guys, once they hear the word cancer, regardless of whether it's low-grade or high-grade, they just want it treated."
Studying the prevalence prostate cancer screening
Despite these recommendations, a USPSTF study published in April 2023 found a lot of unnecessary screening. The cohort consisted of 32,306 men older than 70. Some 50 percent of them had been screened within the previous two years.
The study's authors noted that only 4.3 percent of the men were African-American. That makes it difficult to cite a prevalence of higher-risk groups within the cohort as the reason for what appears to be significant overscreening.
The authors noted some other factors associated with higher levels of screening:
- Being married
- Having a primary care physician
- Having a higher education level
The study suggested that discussing the advantages of screening with a physician was also associated with increased screening. The authors proposed that there may be potential in "...clinician-level interventions to reduce overscreening in older males."
The nuance of prostate cancer screening
If you talk with clinicians dealing with real-world older men and the potential for prostate cancer, the questions of screening may not be so clear cut.
It's true that overall life expectancy in the U.S. has been declining, but many people remain healthy for years, or even decades, past their prime prostate cancer screening years.
"Not every 70-year-old guy is the same," Parekh said. "You have to look at their overall health, life expectancy, that sort of thing. There's a lot of really healthy 70-year-old guys; there's also a lot of guys with a significant family history of aggressive prostate cancer or African-American men. Once you discuss those things with them, there's a lot of guys that request that their PSAs be monitored."
One problem may be that some clinicians aren't very helpful in explaining the exact significance of elevated PSA levels for each individual once the results are in. A less-than-thorough understanding of the Gleason score doesn't help, either.
Perhaps it wouldn't be so crazy to get a little panicked at thinking you might have cancer without additional context—no matter how old you are—and perhaps some of that panic could be prevented.
"This is what is required: an informed discussion between you and your patient," said Daniel P. Petrylak, M.D., the chief of genitourinary oncology at Yale School of Medicine with locations in Greenwich and New Haven, Connecticut. "Once you've run the PSA, you've got to follow up on it. I've seen many cases where it hasn't been followed up on."
Some of the presumed risks of overscreening—that men may undergo unnecessary, stressful and painful procedures such as biopsies or even unnecessary radical prostatectomies—are no longer as pertinent as they once were.
"I don't think the guidelines do a very good job of incorporating the fact that we have a lot more advanced technology when it comes to biomarkers and imaging technologies like (magnetic resonance imaging) MRI," Parekh said. "That plays a lot more of a role in our decision-making where before we would have done a biopsy."
Recent studies suggest more older men are presenting with advanced, metastatic prostate cancer, and some are questioning screening recommendations as one possible culprit.
"There's still a lot of ongoing research on this; most of it's just anecdotal right now," Parekh said. "But that's being studied: Are more patients presenting with advanced prostate cancer since the guidelines changed? So now they're dealing with a lot of negative effects of that. Their quality of life is [not great] for something that, if it had been caught sooner, it could have been cured or treated very easily."
It all comes down to frank and open conversations between physicians and patients. The medical community has made great strides in opening up discussions regarding treatment, educating clinicians to calibrate treatment to best suit each individual patient, and to center the patient's personal preferences.
The AUA even has an acronym for it: shared decision-making (SDM).
While there can never be a perfect system when dealing with something as complicated as the human body, the good news is these professional medical societies and individual clinicians are focused on constant improvement.