[NPInfo] OK, so if doctors don't have to do we still have to?

[David Mittman]

I know I am a pain in the butt (no pun intended) about these things.
Dave




August 5, 2008
Doctors Urged Not to Screen Elderly Men for Prostate Cancer
By TARA PARKER-POPE
In a move that could lead to significant changes in medical care for  
older men, a national task force on Monday recommended that doctors  
stop screening men ages 75 and older for prostate cancer because the  
search for the disease in this group was causing more harm than good.

The guidelines, issued by the U.S. Preventive Services Task Force,  
represent an abrupt policy change by an influential panel that had  
withheld any advice regarding screening for prostate cancer, citing a  
lack of reliable evidence. Though the task force still has not taken a  
stand on the value of screening in younger men, the shift is certain  
to reignite the debate about the appropriateness of prostate cancer  
screening at any age.

Screening is typically performed with a blood test measuring prostate- 
specific antigen, or PSA, levels. Widespread PSA testing has led to  
high rates of detection. Last year, more than 218,000 men learned they  
had the disease.

Yet various studies suggest the disease is “overdiagnosed” — that is,  
detected at a point when the disease most likely would not affect life  
expectancy — in 29 percent to 44 percent of cases. Prostate cancer  
often progresses very slowly, and a large number of these cancers  
discovered through screening will probably never cause symptoms during  
the patient’s lifetime, particularly for men in their 70s and 80s. At  
the same time, aggressive treatment of prostate cancer can greatly  
reduce a patient’s quality of life, resulting in complications like  
impotency and incontinence.

Past task force guidelines noted there was no benefit to prostate  
cancer screening in men with less than 10 years left to live. Since it  
can be difficult to assess life expectancy, it was an informal  
recommendation that had limited impact on screening practices. The new  
guidelines take a more definitive stand, however, stating that the age  
of 75 is clearly the point at which screening is no longer appropriate.

The task force was created by Congress and first convened in 1984 to  
analyze current medical research and to make recommendations about  
preventive care for healthy people. Its guidelines are viewed as  
highly credible and are often relied on by physicians in making  
decisions about patient care.

“When you look at screening, you have a chance the screening will help  
you live longer or better, and you have the chance that screening  
detection and treatment will harm you,” said Dr. Ned Calonge, chairman  
of the task force and chief medical officer for the Colorado  
Department of Public Health and Environment. “At age 75, the chances  
are great that you’ll have negative impacts from the screening.”

It is estimated that one out of every three men 75 and older is now  
screened for prostate cancer, although some studies suggest the number  
is even higher. The Journal of the American Medical Association  
reported in 2006 that in a group of nearly 600,000 older men treated  
by the Veterans Administration, 56 percent of those ages 75 to 79 had  
been screened for prostate cancer. Given the large numbers of men over  
75 who are being screened, even a small decline in testing may greatly  
reduce the number of prostate cancer cases detected.

Dr. Calonge said it was important that the guidelines not be viewed as  
“giving up” on older men. While the new rules should discourage  
routine testing of older patients, the recommendations will not  
prevent a man from seeking screening if he desires it, Dr. Calonge  
said. The new guidelines are not expected to alter Medicare’s current  
reimbursement for annual PSA screening of older men.

“There will be some men who would say, ‘Let’s do it anyway,’ and other  
men who say, ‘If we don’t need to do it, let’s not do it,’ ” Dr.  
Calonge said.

The guidelines focus on the screening of healthy older men without  
symptoms and will not affect treatment of men who go to the doctor  
with symptoms of prostate cancer, like frequent or painful urination  
or blood in the urine or the semen.

Studies of the value of prostate cancer screening for younger men have  
produced mixed results, but a major clinical trial under way in Europe  
will try to determine whether there is any value, in terms of longer  
life expectancy, to screening this group for prostate cancer. Those  
results may be published as early as next year.

While the verdict is still out on younger men, the data for older men  
are more conclusive, experts say. The American Cancer Society and the  
American Urological Association both say annual PSA screening should  
be offered to average-risk men 50 and older, but only if they have a  
greater than 10-year life expectancy.

Recently, Swedish researchers collected 10 years of data on men whose  
cancer was diagnosed after the age of 65 and found no difference in  
survival among those who were treated for the disease and those whose  
cancers were monitored but treated only if the cancer progressed. The  
finding suggests that for most men, stopping screening at 75 is a safe  
option.

“If someone has made it to the age of 75 and they don’t have an  
elevated PSA, the likelihood of them developing clinically significant  
prostate cancer in the last 10 to 15 years of their life is pretty  
low,” said Dr. Peter C. Albertsen, professor of urology at the  
University of Connecticut Health Center. “The downside risk begins to  
outweigh the upside at the age of 75.”

Some studies suggest that as many as half of men 75 and older have  
clinically insignificant prostate cancer that is unlikely to affect  
their health but may be found through a biopsy. If the disease is  
detected as a result of screening, the men may be actively treated  
with radiation or hormone therapies, or may endure the stress of  
“watchful waiting” to see if the disease progresses.

Treatments for prostate cancer can cause significant harm, rendering  
men incontinent or impotent, or leaving them with other urethral,  
bowel or bladder problems. Hormone treatments can cause weight gain,  
hot flashes, loss of muscle tone and osteoporosis.

“I’m very pleased the prevention task force has said, at least for the  
old guys, ‘Leave them alone because our evidence suggests it doesn’t  
help,’ ” said Dr. Derek Raghavan, director of the Cleveland Clinic  
Taussig Cancer Institute. “Taking an 80-year-old and telling him he  
has cancer and telling him he needs radiotherapy or surgery uses up  
medical resources and puts him at risk. It’s a step toward rational  
thinking.”


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