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Stop prostate exams at age 75, panel urges

Treatment takes a toll, and false positives are common. But some see ageism in the advice.

August 05, 2008|Thomas H. Maugh II and Denise Gellene | Times Staff Writers

Men over the age of 75 should no longer be screened for prostate cancer because the potential harm from the test results -- both physical and psychological -- outweighs any potential benefit from treatment, a federal panel said Monday.

Most oncologists already argue against treating most men in that age group for prostate cancer because they are more likely to die from some other cause than from their tumor.

The new guidelines go one step further, saying, in effect, why test if the patient is unlikely to be treated?

The guidelines, published in the Annals of Internal Medicine, are only recommendations, but they are relied on by many physicians in determining patient care.

The recommendations could therefore trigger a decline in prostate cancer testing in the elderly.

The recommendations provoked a backlash from some experts.

"It sounds like a regulation promulgated by an HMO" to save money, said Dr. Dudley Danoff, president of Tower Urology in Los Angeles.

For The Record
Los Angeles Times Wednesday, August 13, 2008 Home Edition Main News Part A Page 2 National Desk 1 inches; 58 words Type of Material: Correction
Prostate cancer: An Aug. 5 article in Section A about new guidelines for prostate cancer screening said the American Cancer Society and the American Urological Assn. recommended a PSA test for men older than 50 if they had a life expectancy of more than 10 years. Both groups recommend only that the test be offered to such men.

"I don't think it is fair to a guy who is 75. Yesterday's 75 is not the 75 of the 1950s. . . . If you stop screening and treating men at 75, you are going to have a lot more people dying of prostate cancer."

Dr. David Penson, associate professor of urology at USC's Keck School of Medicine, called the recommendation "a form of ageism."

"You can't make cookie- cutter recommendations," Penson said, adding that the advice could hurt patients by prompting insurance companies to stop paying for the cancer test, which costs $40 to $60.

Prostate cancer is the most common type of cancer among men after skin cancer. The American Cancer Society estimates that 186,320 new cases of prostate cancer will be diagnosed in the U.S. in 2008 and that 28,660 men will die of the disease this year.

There is controversy about whether to treat prostate cancer, because the tumors can take two forms: a fast-growing, aggressive one or a slowly progressing one that is relatively benign.

Most elderly men have the slow-growing form.

"The problem is that we can't tell which ones are really bad," said Danoff, who had not seen the new guidelines.

The test in question is called the prostate-specific antigen or PSA test, which most men start receiving at the age of 50.

High blood levels of the antigen in the test generally indicate the presence of a tumor. But confirming it requires a biopsy.

Current guidelines from the American Cancer Society and the American Urological Assn. recommend that the test be given to men older than 50 if they have a life expectancy of more than 10 years. But that has been problematic for doctors because gauging life expectancies can be difficult.

The new guidelines were issued by the U.S. Preventive Services Task Force, which was established by Congress to make recommendations about preventive care for healthy people.

In 2002, the Preventive Services Task Force said there was not enough evidence to offer guidelines on prostate screening in the elderly. But there have been at least eight new studies published since then, including a large Swedish study which found that treating men older than 65 did not improve survival.

Increased levels of treatment for prostate cancer in such men, the task force said, was to the serious detriment of their quality of life, with side effects including impotence, incontinence, weight gain, hot flashes and osteoporosis.

Also, the test has a high rate of false positives, leading to unnecessary biopsies, which are painful and carry a risk of infection. Positive tests also upset the patients, the task force said.

"We could not find adequate proof that early detection leads to fewer men dying of the disease," said Dr. Ned Calonge, chief medical officer of the Colorado Department of Public Health and Environment and chairman of the task force. "At this point, we recommend that men . . . make a decision based on their individual risk factors and personal preference."

The panel said the evidence was not conclusive for men younger than 75 and did not issue any recommendations for that group. The National Cancer Institute is now sponsoring a major trial to determine the utility of testing in this group, but results will not be available for years.

"In general, the guidelines make sense," said Dr. Leon Seard, chief of urology at Orange Coast Memorial Cancer Center in Fountain Valley. "We know that prostate cancer is a slow-growing disease and years ago used to say that 70 might be the cutoff. Now that the population is aging and remaining healthy, we are extending that to 75."

The guidelines won't change what he does, he said, because he doesn't routinely screen men over 75 unless they are African American, and thus have an increased risk of having aggressive tumors.

"This is another piece of evidence to present to the patient," he said.

Despite the panel's findings, there is some evidence that treatment is beneficial to the elderly. A 2006 study in about 45,000 men showed that treating tumors in the elderly increased survival by 30%, from an average of 10 years up to 13 years.

"Age, in and of itself, is not a definitive determinant of whether you should be excluded from treatment" for prostate cancer, said Dr. Mark Kawachi of the City of Hope National Medical Center.

Dr. Nick Tomasic, a urologist at Marina Del Rey Hospital, added that the guidelines don't always take into account the complexities of individual cases and the ability of doctors to closely monitor their patients' conditions.

The correct course of action for individual patients, Tomasic said, "is not always so cut and dry."

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thomas.maugh@latimes.com

denise.gellene@latimes.com

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