Are Age-Based Criteria the Best Way to Determine Eligibility for Prostate Cancer Screening?
First published as a set of Letters to the Editor in Annals of Internal Medicine 150(3):220-2, February 3, 2009.
Comment 1 / Comment 2 / Response
TO THE EDITOR: The U.S. Preventive Services Task Force (USPSTF) (1) again tackles a difficult subject in updating their recommendations for prostate cancer screening. The most substantial change in the new guideline is the grade D recommendation against screening men age 75 years or older because of a perceived lack of benefit for prostate cancer treatment in these older men. We would argue, however, that rather than adopting rigid age-based stopping criteria for screening, the medical community should pursue a more nuanced approach to screening, diagnosis, and treatment across all age strata.
Screening and potential overdiagnosis of prostate cancer are concerning primarily the extent that they lead to overtreatment. Overtreatment is certainly a substantial problem among men with low risk prostate cancer, particularly among older men (2). With cessation of screening among older patients, however, we lose the opportunity to detect aggressive prostate cancer in those men who are most likely to have it. The incidence of high-risk prostate cancer increases with age, accounting for 42% of cancers diagnosed in men age 75 years or older compared with 22% in men younger than 75 years (3). As much as overtreatment of low-risk disease remains a concern, we have also found evidence of growing underuse of potentially curative local therapy among the men with high-risk disease who face the highest risk of disease-specific morbidity and mortality (4). Rigid age-based criteria, moreover, ignore substantial variation in life expectancy based on overall health and comorbid illnesses.
We have previously attempted to develop multispecialty consensus recommendations aimed at encouraging a more cautious approach to screening for prostate cancer in men older than 75 years. During these discussions, primary care physicians expressed great interest in continued screening even in older men and were reluctant to stop screening at a predetermined age. After a year-long educational campaign, stated physician preferences for continued screening beyond 75 years fell 20%. However, the demographic correlates of screeners vs non-screeners did not change: Screeners were more likely to be older men themselves (5).
All patients with mildly elevated prostate-specific antigen levels on screening tests do not necessarily require further diagnostic evaluation. Likewise, many older men—probably a substantial majority—in whom lower-risk tumors are diagnosed can be safely followed with active surveillance (6). A greater onus must be placed on physicians (and the men they counsel) to divorce diagnosis from inevitable treatment. Older men who harbor undiagnosed aggressive tumors, however, risk substantial potential morbidity and potential mortality from progressive disease and should not be denied the opportunity for treatment.
Badrinath R. Konety, MD, MBA
Matthew R. Cooperberg, MD, MPH
Peter R. Carroll, MD, MPH
University of California, San Francisco
San Francisco, CA 94143
References
1. U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008:149:185-91.
2. Cooperberg MR, Lubeck DP, Meng MV, Mehta SS, Carroll PR: The changing face of low-risk prostate cancer: trends in clinical presentation and primary management. J Clin Oncol 2004; 22: 2141-9.
3. Konety BR, Cowan JE, Carroll PR; CaPSURE Investigators. Patterns of primary and secondary therapy for prostate cancer in elderly men: analysis of data from CaPSURE. J Urol 2008;179:1797-803; discussion 1803.
4. Cooperberg MR, Cowan J, Broering JM, Carroll PR: High-risk prostate cancer in the United States, 1990-2007. World J Urol 2008; 26: 211-8.
5. Konety BR, Sharp VJ, Raut H, Williams RD. Screening and management of prostate cancer in elderly men: the Iowa Prostate Cancer Consensus. Urology 2008;71:511-514.
Dall'Era MA, Konety BR, Cowan JE, Shinohara K, Stauf F, Cooperberg MR, Meng MV, Kane CJ, Perez N, Master VA, Carroll PR. Active surveillance for the management of prostate cancer in a contemporary cohort.
Cancer 2008;112:2664-70.
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TO THE EDITOR: The USPSTF (1) defines an age cut-off for prostate cancer screening, recommending against screening for men older than 75 years or those with a life expectancy less than 0 years. It may be uncertain whether screening for prostate cancer using prostate-specific antigen is a useful tool at any age. But an age cut-off of 75 years may be wrong for some men aged 75 years or older. As Walter and Covinsky (2) reported, in 1997 the life expectancy was 14.2 years for U.S. men age 75 years in the top 25th percentile of the survival tables, 10.8 years for those age 80 years, and 7.9 years for those age 85 years. For the same age groups in the top 50th percentile, life expectancy was 9.3 years, 6.7 years, and 4.7 years, respectively. In an aging world (3) clinicians, health care providers, and political decision makers must remember that aging differs in people with different health and functional status. The "best agers" have a life expectancy of 4.3 years in men and 4.8 years in women (top 25th percentile) at age 95. Biological age alone is a bad adviser for decision making.
Manfred Gogol, MD
Krankenhaus Lindenbrunn, Klinik fuer Geriatrie
Coppenbruegge 31863, Germany
References
1. U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:185-91.
2. Walter LC, Covinsky KE. Cancer screening in elderly patients. A framework for individualized decision making. JAMA 2001;285:2570-6.
3. Lutz W, Sanderson W, Scherbov S. The coming acceleration of global population aging. Nature 2008;451:716-9.
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IN RESPONSE: We appreciate the letters from Drs. Konety and colleagues and Dr. Gogol regarding the USPSTF's updated recommendation on screening for prostate cancer (1). The USPSTF recommended against screening men age 75 years or older.
First, it is important to emphasize that a systematic review conducted in collaboration with the USPSTF (2) identified no direct evidence (that is, evidence from randomized trials) that permitted the USPSTF to determine whether prostate-specific antigen screening has a net benefit on mortality for men of any age. Although some men may benefit from earlier detection of potentially fatal cases of prostate cancer, others will be harmed by the adverse effects of detection and treatment of seemingly abnormal prostate cells that would never have caused clinical symptoms. We will not know whether the uncontrolled experiment that began in the early 1990s of screening millions of men for prostate cancer has, on the whole, increased or shortened life expectancy until ongoing randomized trials are completed.
In concluding with moderate certainty that the harms of screening men age 75 years or older outweigh the benefits, the USPSTF relied on information about the natural history of clinically detected prostate cancer from a randomized trial comparing the outcomes of radical prostatectomy with watchful waiting (3). This trial suggested that the interval required to experience a mortality benefit from prostate-specific antigen screening is greater than 10 years. Even assuming that every case of prostate cancer detected by screening is potentially fatal (not true) and that treatments are never fatal (also not true), the majority of men age 75 years or older would experience no benefits from screening.
Recently published data from the trial by Bill-Axelson and colleagues (4) suggest that the USPSTF may have set the screening "cut-off" age conservatively. In the trial, men older than 65 years who underwent prostatectomy had the same mortality rate as men who did not (4).
Dr. Konety asserts that older men who are found to have “low-risk” prostate cancer could choose to enter active surveillance rather than undergo treatment, thus reducing the harms associated with prostate cancer screening. In practice, potentially lethal prostate cancers cannot be reliably identified. Because most men desire to remove all traces of cancer, attrition rates from studies of active surveillance have been high, rendering the effectiveness of the surveillance protocol uninterpretable (2). In addition, there is no evidence that active surveillance itself leads to more benefits than harms.
Ned Calonge, MD, MPH
Colorado Department of Public Health and Environment
Denver, CO 80246
Diana B. Petitti, MD, MPH
Department of Biomedical Informatics
Arizona Sate University
Phoenix AZ 85041
Kenneth W. Lin, MD
Agency for Healthcare Research and Quality
Rockville, MD 20850
References
1. U.S. Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008;149:185-91.
2. Lin K, Lipsitz R, Miller T, Janakiraman S; U.S. Preventive Services Task Force. Benefits and harms of prostate-specific antigen screening for prostate cancer: an evidence update for the U.S. Preventive Services Task Force. Ann Intern Med 2008;149:192-9.
3. Bill-Axelson A, Holmberg L, Ruutu M, Häggman M, Andersson SO, Bratell S, et al.; Scandinavian Prostate Cancer Group Study No. 4. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2005;352:1977-84.
4. Bill-Axelson A, Holmberg L, Filén F, Ruutu M, Garmo H, Busch C, et al.; Scandinavian Prostate Cancer Group Study Number 4. Radical prostatectomy versus watchful waiting in localized prostate cancer: the Scandinavian prostate cancer group-4 randomized trial. J Natl Cancer Inst 2008;100:1144-54.
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Current as of February 2009
Internet Citation:
Are Age-Based Criteria the Best Way to Determine Eligibility for Prostate Cancer Screening? Published Comments and Response: Letters to the Editor and Response. First published in Annals of Internal Medicine 150(3):220-2. Agency for Healthcare Research and Quality, Rockville,
MD. http://www.ahrq.gov/clinic/tfcomments/tfprostcom.htm
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