PSA screening launches cascade of treatment, complications

Advancing age and worsening comorbidity were associated with fewer prostate biopsies after abnormal PSA screening results; however, biopsy-detected cancer often led to treatment regardless of age, comorbidity or cancer status, according to a study published online April 15 in the Journal of the American Medical Association.  

Although the U.S. Preventive Services Task Force, American Cancer Society and American Urological Association recommend against PSA screening in men with limited life expectancy, Medicare covers the exam and many men ages 65 years and older undergo screening.

Louise C. Walter, MD, of the division of geriatrics at San Francisco VA Medical Center, and colleagues sought to calculate five-year downstream outcomes among men ages 65 years and older after a PSA screening result of 4.0 ng/mL.

The researchers reviewed the records of 295,645 men ages 65 years and older (mean age, 73 years) who underwent screening in the VA healthcare system in 2003 and were followed for five years.

A total of 25,208 men had an index PSA level exceeding 4.0 ng/mL or higher. Thirty-three percent of these men underwent at least one prostate biopsy during the five-year follow-up, and 62.8 percent of these men were diagnosed with prostate cancer. A total of 82.1 percent of men diagnosed with prostate cancer were treated for prostate cancer.

Treatments performed included potentially curative radical prostatectomy or radiation therapy for 58.1 percent of men, and noncurative hormone therapy for 23.9 percent of men.

Abnormal PSA results increased with advancing age; 5.9 percent of men aged 65 to 69 years had an abnormal result compared to 17.3 percent of men ages 85 years or older. Five-year survival among men treated for prostate cancer was 82.1 percent; however, this rate dropped with advancing age and worsening comorbidity.

A total of 5.6 percent of men who underwent biopsy after screening had complications, which resulted in 131 hospitalizations and nine deaths. Among the treated group, 13.6 percent reported new incontinence and 13.7 percent reported new erectile dysfunction.

The percentage of men age 75 years and older with an abnormal screening result increased with age, but only one-third of these men underwent biopsy. While most of these men with abnormal results did not undergo biopsy, the cancer detection rate was higher and most men diagnosed as having cancer received immediate treatment. 

In fact, patients often were treated regardless of advancing age, poor health or low-risk cancer, according to Walter et al. “Yet, this is the step in the downstream cascade where increasing evidence supports unlinking cancer detection from immediate treatment and pursuing active surveillance with selective, delayed treatment, especially in older men with comorbidities.”

Walter and colleagues concluded, “These findings suggest a need to better incorporate considerations of advancing age, worsening comorbidity, and aggressiveness of screen-detected cancer into treatment decisions.”

For more about prostate cancer, please read “Prostate Cancer: In the Eye of the Storm,” in Health Imaging.