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Should men over the age of 65 years receive PSA screening? Argument in favor

Nature Clinical Practice Urology volume 5, pages 230–231 (2008)Cite this article

In 2007, an estimated 27,050 deaths occurred as a result of prostate cancer in the US, which represents a 2.2% lifetime risk of prostate cancer death. Prostate cancer is the second leading cause of cancer-specific mortality in American men, accounting for 9% of cancer-related deaths.1 Screening for prostate cancer is the subject of much controversy. At least two major guidelines, one published by the American Urological Association and another from the American Cancer Society, unequivocally recommend prostate cancer screening for men over the age of 50 years with a life expectancy of at least 10 years; however, neither guideline specifies an age at which screening should be stopped.

According to the most recent data from the Surveillance Epidemiology and End Results (SEER) database, over 60% of prostate cancer diagnoses occur in men over the age of 65 years. Additionally, in our analysis of the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) study, 71% of the most aggressive tumors (Gleason grade 8–10) occur in men over the age of 65 years (BR Konety, unpublished data; see Supplementary Figure 1 online), corresponding to roughly 30,000 new high-grade tumors in these elderly men each year. The natural history of clinically detected prostate cancer in elderly men is well known from the prostate cancer survival tables published by Albertsen and colleagues.2 A mathematical model has now found that prostate cancer detected by screening precedes clinical detection by 14 years for Gleason grade ≤6 tumors, 9 years for Gleason grade 7 tumors, and 5 years for Gleason grade 8–10 tumors;3 therefore, the survival data in the Albertsen et al. tables can be adjusted by this lead time bias (see Supplementary Table 1 online). In the US, the life expectancy of 65-year-old and 75-year-old men approaches 20 and 10 years, respectively. In a 65-year-old patient with a Gleason grade 8–10, 7, or 6 tumor, the estimated prostate-cancer-specific mortality at 20 years would be 70%, 40%, and 10%, respectively. In a 75-year-old patient with a Gleason grade 8–10 cancer, the estimated prostate-cancer-specific mortality at 10 years would still be 25%. Thus, high-grade cancers are lethal even in patients aged 75 years and older, while intermediate-grade cancers, and arguably even low-grade cancers, pose a mortality risk in men aged 65 years or older.

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Acknowledgements

We thank Gloria Won of the HM Fishbon Memorial Library for her help with the literature review.

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Authors and Affiliations

  1. JM Whitson is a 5th Year Resident and BR Konety is an Associate Professor of Urology at the Department of Urology, University of California San Francisco, San Francisco, CA, USA.,

    Jared M Whitson & Badrinath R Konety

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  1. Jared M Whitson
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  2. Badrinath R Konety
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Correspondence to Jared M Whitson.

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The authors declare no competing financial interests.

Supplementary information

Supplementary Figure 1

D'Amico risk group classification by age (DOC 51 kb)

Supplementary Table 1

Estimated prostate-cancer-specific mortality of patients with localized screen-detected cancer managed conservatively (DOC 44 kb)

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Whitson, J., Konety, B. Should men over the age of 65 years receive PSA screening? Argument in favor. Nat Rev Urol 5, 230–231 (2008). https://doi.org/10.1038/ncpuro1078

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