PSA screening rates soar beyond guideline limits

San Francisco-AUA's recommendation that PSA screening for prostate cancer be avoided in men with an anticipated life expectancy of less than 10 years appears to be a guideline more honored in the breach, according to a study from the San Francisco VA Medical Center published in JAMA (2006; 296:2336-42).

In an analysis of the records of 597,642 male veterans 70 years of age and older, the researchers found that more than one-third (36%) of veterans age 85 years and older had received a PSA screening, and almost two-thirds (64%) of men between 70 and 74 years of age had been screened.

One of the study's more surprising findings was the amount of testing done in patients with serious, life-shortening comorbid conditions. The authors found only a 7% difference between the testing rate in healthy elderly men and the rate in those with poor health, including those with Charlson scores of 4 or higher, indicating a four-fold risk of death (58% vs. 51%). Among men 85 years or older, those in the best health had a higher screening rate (36%) compared to those in worst health (34%).

The authors speculated that excessive, unwarranted testing might be the product of multiple factors, including the widespread promotion of PSA testing in the media and outreach programs that do not carry information about the hazards of testing in the elderly. Clinicians may be uncertain of a patient's life expectancy, even in the face of serious comorbid conditions. This may be attended by a fear of malpractice litigation, should the patient develop prostate cancer. Further, the study's findings might have been skewed because men in the cohort visited clinicians more frequently to address illnesses that attend aging; thus, they would be more likely to be screened.

"Patients do not realize that there are downsides to the screening," Dr. Walter told Urology Times. "For clinicians, it is easier to schedule the test than to have a discussion about benefits and harms. In addition, when clinicians recommend against the test, people wonder if they are only trying to save money. There are also surveys that show a high percentage of patients, including elderly patients, who feel they are being irresponsible by not taking screening tests."

Among the solutions she proposed were development of educational materials that more clearly explain testing in the elderly; more accurate and reliable scales for estimating longevity or better use of existing scales, such as the Charlson index; and more time spent by clinicians and their aides to educate patients about the limited benefits and harms of screening older men.

In addition to AUA and the VA, other organizations recommending against testing in men with estimated life expectancies of less than 10 years include the American Academy of Family Physicians, the American Cancer Society, the American College of Physicians-American Society of Internal Medicine, and the U.S. Preventive Services Task Force.