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NEW data on prostate-specific antigen levels in older Australian men challenge the current “one-size-fits-all” approach on PSA elevation, according to experts.
The cohort study in men aged 70 years and over found more than one in 10 had an elevated PSA level (greater than or equal to 6.5 ng/mL), and this figure increased to almost a third among men aged 90 years and over. (1)
It also found that a significant number of older men reported having PSA tests performed recently.
The researchers said their study of 1434 men who had not been diagnosed with prostate cancer — part of the Concord Health and Ageing in Men Project (CHAMP) — was the largest population-based study to have measured PSA in men aged over 70 years and the first to look at men aged over 85 years.
Professor Bruce Armstrong, of the School of Public Health at the University of Sydney, said the study reinforced the point that PSA levels increased with age, probably mainly due to an increasing incidence of benign conditions rather than increased instances of prostate cancer.
“This reinforces the understanding that if we are going to go forward rationally with PSA testing, we need to use age-related norms of PSA levels rather than a one-size-fits-all approach.”
The researchers said nearly half of study participants reported having a PSA test in the previous 2 years, despite recommendations against screening in this age group.
Professor Armstrong said these figures revealed inappropriate levels of screening in very old men. It was widely accepted and included in international guidelines that men who have an expectation of less than 10 years of life should not be having PSA tests.
Although this applied to men aged 80 years and older, the study found that 41% of men aged 80-84 years had a PSA test in the previous 2 years, as had 29% of those aged 85-89 years and 13% of those aged 90-99.
“That screening shouldn’t be happening. This reminds us it is happening, and to a degree that’s really quite unacceptable”, Professor Armstrong said.
Professor Alexandra Barratt, a professor of epidemiology at the University of Sydney, agreed. “Prostate cancer screening in men over 75 years is not recommended because screening in this age group will do harm and the benefit is small to none.
“I think the CHAMP findings support this position because they show that screening men over 75 years will result in 10%-15% of men having a high PSA level, which could result in them being investigated and treated unnecessarily”, Professor Barratt said.
However, Professor David Currow, chief executive officer of the Cancer Institute NSW, said that at a policy level, screening guidelines should continue to be reviewed.
“Life expectancy is quite good in 2012, so we need to be aware that as the population ages in an unprecedentedly healthy way in human history, we need to keep reviewing the upper age limits for those screening programs.”
Dr Stephen Ruthven, Urological Society of Australia and New Zealand president, said the study also raised the issue of whether there should be ethnic or race-specific PSA values for men in older age groups.
The study showed that older men born in Italy, the UK, Ireland, Greece or China had lower median PSA levels than Australian-born men.
Dr Ruthven said the study also provided reassurance for primary care physicians that it was reasonable to repeat a PSA test to ensure the level was just elevated and not elevating. He said referral for biopsy should only be recommended if the PSA level was found to be rising quickly.
– Amanda Bryan
Posted 26 March 2012
I agree SCREENING in this age group is probably of minimal value. However a PSA where there are good clinical reasons to suspect a possible cancer is another story, as even at 70+ if the cancer is aggressive and the man fit, consideration of treatment is warranted.
A healthy, active and employed 68-year-old man with no family history of prostate cancer in his long-living male relatives, except for his maternal grandfather, presented with minor perineal discomfort/paraesthesia of approximately three weeks duration and no other symptoms. A digital rectal examination of the prostate indicated a suspicious ridge on the right and a PSA test showed a level of 1.8 ng/mL, the overall rise being from only 1.2 to 1.8 ng/mL over a 15-year period. A trans-rectal ultrasound did not indicate any pathology but a biopsy indicated a T2a adenocarcinoma with a Gleason score of 6. A laparoscopic radical prostatectomy pathology report stated prostate adenocarcinoma, Gleason Grade 4 + 3 = 7. (See LGF Giles, J R Soc Med Sh Rep 2010;1:38 for full details, literature review, discussion and conclusions). As Ray T posted, “if one life is saved the cost is warranted”.
I avoided the “PSA screen” until about 5 years ago. Had an elevated level been found (it wasn’t) I would have asked for further monitoring rather than having random biopsies. I am of course, biased being a retired pathologist about to celebrate my eighty-fifth birthday. I think the “challenge” is valid!
If one life is saved the cost is warranted. I am biased – if age-related norms were given dominance my own very early prostate CA would not have been detected as early as it was. My levels were not all that elevated by age-related norms, but had jumped rapidly from my personal norm, and were correctly seen as an indication for biopsy.