With all the positive new options in cancer screening, it may come as a surprise to hear that the US Preventive Services Task Force, an independent panel of prevention and primary care experts, has issued new guidelines recommending that men age 75 and older should not undergo prostate cancer screening…but it may actually make sense. As is often the case, there are several layers to the issue.
It’s not that men over 75 have reduced risk for prostate cancer—rather, the recommendation was prompted by a concern that in older men, positive test results may lead to dangers worse than those posed by slow-growing prostate cancer. Published in the August 5, 2008, issue of the Annals of Internal Medicine, the task force concluded that over the long term, prostate screening is not likely to benefit most men over the age of 75. This is because the subsequent treatments offered are associated with assorted significant risks in the short term.
According to David F. Penson, MD, MPH, associate professor of urology at the University of Southern California, the test results aren’t very reliable—the many false positives and false negatives can sometimes bring more harm than good. For instance, if test results suggest cancer, the next step is a painful prostate biopsy to definitively diagnose the disease. This begins “a cascade of possible harms,” said Dr. Penson, such as infection or bleeding from prostate biopsies and, if cancer is found, risks from surgery or radiation treatment that may include erectile dysfunction, urinary incontinence, bowel dysfunction and sometimes death. While the obvious benefit of prostate cancer screening is that it potentially saves lives, most prostate cancers grow very slowly. Often such men would never have developed cancer symptoms in their lifetime. Because the average 75-year-old man can expect to live about 10 more years, many are more likely to die of other causes, such as heart disease or stroke in that time frame.
Dr. Penson also said he’s not entirely comfortable with the new guidelines though. Noting that the goal is a population-wide recommendation that is “reasonable,” he described a hypothetical 77-year-old patient with a family history of longevity, who runs half-marathons and has no apparent risk factors for cardiac disease. Such a man’s life expectancy is more than 10 years, so it would not be in his best interest to forego prostate screening. Another concern, says Dr. Penson, is that the new guidelines may give insurance companies a reason not to pay for screening and treatment in men older than 75, which could lead to more deaths from prostate cancer.
These guidelines are not rules—they are merely recommendations. I asked Dr. Penson how men should determine whether or not to have regular prostate screenings past the age of 75. “Have a long and frank discussion with your doctor about your life expectancy and the benefits versus harms of the treatments that might follow abnormal results in your particular situation,” he said, pointing out that in the end, the decision to get screened or seek treatment—or not—should be made individually. If you get screened and are found to have cancer, you still have choices—one of which is to say no to aggressive treatment.
