Should a 73-year-old man with comorbidities and elevated Prostate-Specific Antigen (PSA) undergo further workup for prostate cancer?

PSA Workup in a 73-Year-Old Man with Comorbidities

For a 73-year-old man with comorbidities and elevated PSA, further workup should generally NOT be pursued unless he is very healthy with a life expectancy exceeding 10 years. 1

Decision Algorithm Based on Patient Factors

Age Considerations

• The NCCN guidelines clearly state that PSA testing in men older than 70 years should be performed with caution and only in very healthy men with little or no comorbidity 1
• Very few men above age 75 benefit from PSA testing 1
• Men with limited life expectancy are unlikely to benefit from prostate cancer detection and treatment 1

Comorbidity Assessment

When evaluating whether to pursue workup for elevated PSA in a 73-year-old man, consider:

1. Life expectancy evaluation:

   • Only men with life expectancy >10 years should be screened at any age 1
   • The presence of comorbidities significantly reduces potential benefit from prostate cancer detection

2. PSA level stratification:

   • Men aged 75 years with PSA <3.0 ng/mL have very low risk of dying from prostate cancer 1
   • Consider using a higher PSA threshold (>4.0 ng/mL) for biopsy in men over 70 years to reduce overdiagnosis 1

3. Risk of overdiagnosis:

   • Among men aged 70-79 years, half or more of cases detected by PSA screening with PSA <10 and Gleason score ≤6 are overdiagnosed 1
   • Overdiagnosis leads to unnecessary treatment with potential side effects affecting quality of life

Rationale Against Routine Workup

The AUA guidelines specifically discourage routine PSA screening in men over 70 years based on:

• Absence of evidence of screening benefit in this population 1
• No reduction in mortality among men ≥70 years in the ERSPC randomized trial 1
• Increased competing mortality compared to younger men 1
• Lack of compelling evidence of treatment benefit, especially with limited life expectancy 1

Exceptions Where Workup May Be Considered

In limited circumstances, further workup might be appropriate:

• Very healthy 73-year-old with no significant comorbidities and >10-year life expectancy
• Rapidly rising PSA (concerning PSA velocity) which correlates with more aggressive disease 1
• Very high PSA level (>10 ng/mL) which has higher likelihood of clinically significant disease 1

Potential Pitfalls

• False positives: Approximately 2 of 3 men with elevated PSA do not have prostate cancer 1
• Overdiagnosis and overtreatment: Many prostate cancers in older men are indolent and would never cause symptoms or death 1
• PSA alterations from medications: Medications like finasteride can reduce PSA by approximately 50%, requiring adjustment when interpreting results 2
• Comorbidity impact: Men with moderate/severe comorbidities have competing risks of death that often outweigh potential benefits of prostate cancer treatment 3

In conclusion, for most 73-year-old men with comorbidities, further workup of an elevated PSA is not recommended as the potential harms (overdiagnosis, anxiety, unnecessary procedures) typically outweigh the benefits in terms of mortality reduction and quality of life.