Raoul Concepcion

At What Age Should the Test Stop?

Here we go again. A study published in the March 28 issue of The Journal of Clinical Oncology has raised yet another question about the PSA blood test: When should men stop being screened to detect prostate cancer?

“This is obviously a topic that is not new in terms of controversy,” said Raoul Concepcion, MD, a urologist on staff at Baptist Hospital and a provider with Nashville-based Urology Associates.

The topic is the prostate-specific antigen (PSA) test, which detects the presence of a specific protein released by prostate cells. If that protein is present, it might indicate prostate cancer. The test was introduced commercially in the early 1990s.

A Little History

“Prior to PSA, there was really no good screening test,” Concepcion explained. There was just a very nonspecific blood test and a digital rectal exam. “What we saw once PSA started becoming more widely used … was a quadrupling of the number of cases,” he added.

Critics of what they call “overuse” of the PSA test attribute the test to the increased number of cases, and that’s certainly correct. Yet Concepcion believes the concept of screening is a little more complicated than that. “If you talk to a statistician, screening means that, if the test is positive, you have whatever you’re looking for. If it’s negative, you don’t have it. But no one has ever said that PSA is a good screening test for prostate cancer. If you keep that in mind, your real question then is, when should we start in terms of early-detection programs? It sounds like semantics, but that’s really the case. We’re talking about the use of PSA for early detection, not in the use of screening.”

Concepcion said the issue “came to a head” in March 2009, when The Wall Street Journal cited two studies that questioned the value of PSAs as a screening tool. Together, the two studies involved 240,000 men. Data from a study run by the National Cancer Institute found, after seven to 10 years of follow-up, no benefit from prostate screening. A second European study did find, after nine years of follow-up, a benefit to screening, but the benefit comes at a hefty price. “By the European data, saving one life from prostate cancer would require treatment of 48 men. In other words 47 men would be unnecessarily treated – many suffering urinary or sexual problems – for every life saved,” The WSJ reported.

Thus, the debate of when PSA tests should begin and how often the tests should be administered became a subject of heated debate in urology circles.

“Prior to that, within the urology world and the American Cancer Society, most of us said that an appropriate program for early detection would be to start an annual, digital rectal exam and blood test at age 50,” Concepcion explained. “However, if you are in a high-risk category, such as those with a family history of prostate cancer and/or African American, you should probably start at age 40. That’s pretty much what most of us still do.”

New Research Adds Twist

The study results released in March found that men in their 70s are being PSA-tested at nearly twice the rate of men in their 50s. What’s more, data concluded that men ages 80 to 85 receive the test as often as those 30 years younger. The lead author of the journal article, Scott E. Eggener, MD, a University of Chicago urologist, was quoted in The New York Times, saying the study results are “mind-boggling.” He added, “What we were hoping was that young, healthy men who were most likely to benefit would be screened at higher rates and that screening would tail off in older men.”

Prostate cancer is a slow-growing cancer. Senior men may die with prostate cancer, oftentimes undetected, but it’s rare that the cancer kills them. Concepcion said the recent study has kicked up renewed discussions about the test. “No one ever really talked about when you should stop doing it,” he said. “I will tell you personally that I don’t do them if I don’t think a person can live 10 years. I don’t do absolute cutoffs, but the life expectancy of most 80-year-olds is not 90.” On the flip side, he said patients with a life expectancy of 10 years or more “should be offered definitive therapy.” That’s basically the position of the American Cancer Society and the American Urological Society as well.

Overuse of the PSA test and resulting overtreatment has been more than just a clinical debate. It’s also a political concern, as the nation works to reduce its debt and reform healthcare delivery. “To be honest with you, I think it’s politics and money because everybody is trying to figure out how to bend that cost curve,” Concepcion said.

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