National trends in prostate cancer screening among older American men with limited 9‐year life expectancies: Evidence of an increased need for shared decision making

Abstract

BACKGROUND: Prostate-specific antigen (PSA) screening for prostate cancer remains controversial. Most groups recommend informed decision making for men with 10 years of remaining life expectancy. The primary objective of this observational cohort study was to investigate the association between predicted 9-year mortality and prostate cancer screening among American men aged 65 years in 2005 and 2010. The second objective was to analyze the proportions of men who discussed screening with their physicians. METHODS: Data were extracted from the 2005 and 2010 National Health Interview Surveys. Men aged 65 years without prostate cancer were divided into predicted 9-year mortality quartiles. The proportions of men confirming a screening PSA within the prior year were determined. Logistic regression was used to compare screening rates. RESULTS: Screening rates for men aged 65 years were 48% in 2005 and 48% in 2010 (P 5.9). Men ages 65 to 74 years who had <27% predicted 9-year mortality were most commonly screened, with 56% screened in 2010, compared with 34% of men aged 75 years with >75% predicted 9-year mortality. Approximately 55% of screened men aged 75 years who had 53% predicted 9-year mortality recalled discussing the advantages of screening, whereas 25% recalled discussing the disadvantages. CONCLUSIONS: Prostate cancer screening with PSA did not differ significantly between 2005 and 2010 for men aged 65 years based on predicted 9-year mortality. Approximately 33% of older men with a high likelihood of 9-year mortality were screened despite minimal clinical benefit. Twice as many men recalled discussing the potential advantages of screening compared with the disadvantages.

Factors Related to Prostate-Specific Antigen–Based Prostate Cancer Screening in Primary Care: Retrospective Cohort Study of 120,587 French Men Over the Age of 50 Years (Preprint)

“…Surprisingly, more than 30% of patients treated with anticholinesterase therapies and 20% of patients with six or more ambulance transportations during the study period underwent a PSA-based prostate screening. While all the guidelines recommend avoiding screening in patients with a life expectancy of less than 10 years [8] [18] [34][35], previous authors have also reported inappropriate screening practices in vulnerable patients [36][37][38]. These results emphasize that integrating life expectancy into medical decisions remains a challenge for primary care physicians [39][40].…”

Gleason 6 Prostate Cancer: Translating Biology into Population Health

“…24,25 Conversely, approximately 45% of men in their 70s undergo PSA based screening, even those at high risk for other cause mortality, exposing these patients to the risks of detection and treatment without measurable survival benefit. 26 …”

“…42 Large numbers of older men undergo PSA screening with a low likelihood of benefit 26 and determining who can safely stop screening is important. Among a large cohort of men from Sweden it has been demonstrated that men with a PSA less than 1 ng/ml at age 60 have a risk of prostate cancer death by age 85 of 0.2%.…”

Unorganized Prostate-specific Antigen–based Screening for Prostate Cancer: More Harm than Benefit. When Will We Finally Start to Implement Guidelines and Risk Assessment Tools in Clinical Practice?

“…In addition, the authors conclude that the current UK policy allowing all men to make an informed choice about PSA testing is not being effectively implemented [9]. In the USA, approximately 33% of older men with a high likelihood of 9-yr mortality are screened despite minimal clinical benefit [10]. Data on PSAtriggered prostate biopsy and repeat biopsy (after an initial negative biopsy) are also discouraging, with positive predictive values of 12-50% and many men undergoing repeated biopsy.…”