Why is Prostate-Specific Antigen (PSA) screening not recommended for patients of advanced age?

From the Guidelines

PSA testing is not recommended for men of advanced age (typically over 70-75 years) because the potential harms outweigh the benefits. The primary reason is that prostate cancer in elderly men often progresses slowly, and these men are more likely to die from other causes before the cancer becomes clinically significant or symptomatic 1. Screening can lead to unnecessary anxiety, additional testing (including biopsies), and treatments that may cause significant side effects such as urinary incontinence and erectile dysfunction without extending life expectancy.

Some key points to consider include:

• The U.S. Preventive Services Task Force specifically recommends against PSA screening in men 70 years and older 1.
• The lead time between detection through PSA screening and clinical symptoms is often 10-15 years, meaning that for men with limited life expectancy, early detection provides little benefit.
• Treatment decisions should focus on quality of life considerations rather than aggressive interventions that may not improve outcomes in this population.
• Instead, clinicians should prioritize addressing more immediate health concerns and maintaining functional status in elderly patients.

It's also important to note that the evidence suggests that the benefits of PSA screening are uncertain, and the harms are well-documented 1. Therefore, clinicians should not order the PSA test without first discussing with the patient the potential but uncertain benefits and the known harms of prostate cancer screening and treatment. Men should be informed of the gaps in the evidence and should be assisted in considering their personal preferences before deciding whether to be tested 1.

From the Research

Reasons for Not Conducting PSA on Patients of Advanced Age

• The decision to discontinue prostate-specific antigen (PSA) screening in older men is largely based on life expectancy, as screening may not provide a survival benefit for those with limited life expectancy 2.
• Studies have shown that PSA screening rates decline with age, and men with lower life expectancies are less likely to undergo screening 2.
• The optimal time to discontinue screening is unknown, but factors such as age, life expectancy, and overall health status are considered when making this decision 2.
• Active surveillance, which involves monitoring patients with low-risk prostate cancer, may be an alternative to immediate treatment, but its effectiveness compared to watchful waiting or curative treatments is still being studied 3, 4.
• The natural history of prostate cancer is often indolent, and observational management strategies, including active surveillance, may be suitable for men with low-risk disease 4.

Considerations for PSA Screening in Older Men

• Life expectancy is a significant factor in determining the benefits of PSA screening, and men with limited life expectancy may not benefit from screening 2, 5.
• The presence of comorbidities, older age, and lower Gleason score are predictors of no initial active treatment, which may include PSA screening 4.
• There is no standardized definition of active surveillance, and its distinction from watchful waiting and other observational management strategies is unclear 4.
• Ongoing clinical trials may provide information on the comparative effectiveness of active surveillance compared to immediate active treatment, but long-term follow-up is required 4.