From the Guidelines
For an 87-year-old asymptomatic man with a PSA of 14, I strongly recommend against further evaluation or treatment, as the risks of screening and treatment outweigh the potential benefits in this age group. Given the patient's advanced age, the approach should be focused on maintaining quality of life and avoiding overtreatment. The evidence from the American College of Physicians (1) suggests that screening for prostate cancer using the PSA test is not recommended for men over 69 years or those with a life expectancy of less than 10 to 15 years, due to the substantial harms associated with screening and treatment.
The potential harms of screening and treatment include false-positive results, overdiagnosis, overtreatment, and downstream harms such as infections, urinary incontinence, and erectile dysfunction (1). In contrast, the benefits of screening are limited, with a small potential mortality benefit that may not outweigh the harms for most men.
Key considerations in this case include:
- The patient's age and life expectancy, which suggest that the potential benefits of screening and treatment are unlikely to outweigh the harms
- The asymptomatic nature of the patient's condition, which suggests that the cancer may not be aggressive or clinically significant
- The potential for overtreatment and its associated harms, which can significantly impact quality of life
In light of these considerations, a watchful waiting approach or observation may be more appropriate than active treatment, especially for low or intermediate-risk disease. This approach prioritizes maintaining quality of life and avoiding overtreatment, while still addressing any significant cancer risk. The American College of Physicians guidance statement (1) supports this approach, recommending that clinicians should not screen for prostate cancer using the PSA test in average-risk men over 69 years or those with a life expectancy of less than 10 to 15 years.
From the Research
Prostate-Specific Antigen (PSA) Levels and 5-Alpha Reductase Inhibitors (5-ARIs)
- An 87-year-old asymptomatic individual with a PSA level of 14 may require careful consideration of the potential effects of 5-ARIs on PSA levels 2.
- 5-ARIs, such as finasteride, can reduce serum PSA levels over time, with a noticeable reduction up to 48 months after starting therapy 2.
- The reduction in PSA levels can improve the diagnostic performance of PSA in screening for prostate cancer, but may also lead to a reduction in the diagnosis of indolent cancers 2.
Clinical Implications and Monitoring
- Any increase in PSA from nadir should be considered suspicious for malignancy, and other factors such as digital rectal examination, age, family history of prostate cancer, and imaging techniques should be taken into account in clinical and diagnostic follow-up 2.
- Urologists may use different methods for monitoring PSA levels, including the "doubling rule" and "increase from nadir", with most monitoring PSA every 6 months 3.
- The potential for 5-ARIs to mask prostate cancer is a concern among urologists, and standard guidance and continuous education are needed to support optimal monitoring and interpretation of PSA levels 3.
Efficacy and Safety of 5-ARIs
- 5-ARIs have been shown to reduce the risk of prostate cancer, but may also increase the risk of high-grade disease in men undergoing regular screening 4.
- Finasteride monotherapy has been found to have a moderate effect on reducing prostate volume and a significant effect on improving IPSS score and Qmax, but may be associated with sexual health dysfunctions 5, 6.
- Adverse events associated with 5-ARIs include decreased libido, ejaculatory disorder, gynecomastia, and impotence, highlighting the need for careful consideration of the benefits and risks of 5-ARI therapy 6.