The “New” Prostate Cancer InfoLink has long taken the position defined by the Iowa Consensus , that PSA testing in men aged 75 and older should be based on the health characteristics and life expectancy of individual patients, as compared to an arbitrary cut-off of PSA testing in all men at age 75 years. A recent study by Hoffman et al. has provided some data that helps us to understand the situation in the “real world.”
Hoffman and her colleagues attempted to assess the impact of health status and life expectancy on the use of PSA testing in older men in the United States before the announcement of the 2008 United States Preventive Services Task Force (USPSTF) guidelines which recommended the elimination of PSA testing for all men of ≥ 75 years. The study was based on data from 718 men age 75 years or older with no history of prostate cancer who participated in the 2005 National Health Interview Survey (NHIS)
The life expectancy of the 718 participants was estimated based on their ages and their self-reported health status. The study results showed that:
19 percent of the participants were ≥ 85 years of age.
27 percent of participants reported fair or poor health.
214/718 men (29.8 percent) had a life expectancy of > 10 years.
320/718 men (44.6 percent) had a life expectancy of 5 to 10 years.
182/718 men (25.3 percent) had a life expectancy of < 5 years
In the previous 2 years, 52 percent of all participants had had a PSA test.
Men with fair or poor health were less likely to receive a PSA test than those with excellent or very good health (adjusted OR 0.51, after adjustment for age, race, education and physician access).
42 percent of the men predicted to live < 5 years and 65 percent of the men predicted to live > 10 years reported having recent PSA tests.
There authors drawn no specific conclusions from these data. They merely state that, “Before the United States Preventive Services Task Force recommendation, health status and life expectancy were used to select older men” for PSA testing, and that many men with a life expectancy of < 5 years were being tested. They also note that a strict age cutoff for PSA testing at age 75 years prohibits testing in healthy older men with a long life expectancy who may benefit from screening.
The data on these 718 older men who participated in the NHIS represent data from an estimated 4.47 million non-institutionalized men in the United States. (And it is probably fair to assume that most men living in institutionalized settings who are 7 5 years of age or more do not have a life expectancy of > 10 years.) If one extrapolates from the data presented by Hoffman et al., one finds that, prior to the issuance of the USPSTF guidelines in 2008:
25.3 percent of 4.17 million men ≥ 75 (i.e., 1.06 million men) had a life expectancy of < 5 years, and PSA tests in these men are almost certainly not useful except in the small proportion of these men who are prostate cancer patients and in whom PSA tests are being used to monitor active disease.
44.6 percent of 4.17 million men ≥ 75 (i.e., 1.86 million men) had a life expectancy of 5 to 10 years, and PSA tests in these men are arguably of little value (except, again, in actual prostate cancer patients for whom disease is being followed).
29.8 percent of 4.17 million men ≥ 75 (i.e., 1.24 million men) had a life expectancy of >10 years, and PSA tests in these men may well be worthwhile, but would be excluded based on the USPSTF guidelines.
It is also worth noting that these data probably reflect a bias toward men who are in better health anyway. Non-institutionalized men who were sick or very sick would surely have been significantly less likely to participate in this study that those who were reasonably healthy, and so there is a significant possibility that, actually, the percentages of men with life expectancies ≤10 years are higher and the percentage of men with a life expectancy > 10 years is lower.
If you boil this down to cost issues, the USPSTF guidance is probably saving the costs of something like 52 percent of 4.17 million PSA tests a year (i.e., 2.17 million PSA tests). Is this a good thing or a bad thing? No comment. A man who was turning 75 at his next birthday, and had a life expectancy at that time of 15+ years, might have a very strong opinion, however.
The “New” Prostate Cancer InfoLink will continue to take the position that the USPSTF guidelines make a good deal less sense than those proposed in the Iowa Consensus.
The “New” Prostate Cancer InfoLink has long taken the position defined by the Iowa Consensus , that PSA testing in men aged 75 and older should be based on the health characteristics and life expectancy of individual patients, as compared to an arbitrary cut-off of PSA testing in all men at age 75 years. A recent study by Hoffman et al. has provided some data that helps us to understand the situation in the “real world.”
Hoffman and her colleagues attempted to assess the impact of health status and life expectancy on the use of PSA testing in older men in the United States before the announcement of the 2008 United States Preventive Services Task Force (USPSTF) guidelines which recommended the elimination of PSA testing for all men of ≥ 75 years. The study was based on data from 718 men age 75 years or older with no history of prostate cancer who participated in the 2005 National Health Interview Survey (NHIS)
The life expectancy of the 718 participants was estimated based on their ages and their self-reported health status. The study results showed that:
There authors drawn no specific conclusions from these data. They merely state that, “Before the United States Preventive Services Task Force recommendation, health status and life expectancy were used to select older men” for PSA testing, and that many men with a life expectancy of < 5 years were being tested. They also note that a strict age cutoff for PSA testing at age 75 years prohibits testing in healthy older men with a long life expectancy who may benefit from screening.
The data on these 718 older men who participated in the NHIS represent data from an estimated 4.47 million non-institutionalized men in the United States. (And it is probably fair to assume that most men living in institutionalized settings who are 7 5 years of age or more do not have a life expectancy of > 10 years.) If one extrapolates from the data presented by Hoffman et al., one finds that, prior to the issuance of the USPSTF guidelines in 2008:
It is also worth noting that these data probably reflect a bias toward men who are in better health anyway. Non-institutionalized men who were sick or very sick would surely have been significantly less likely to participate in this study that those who were reasonably healthy, and so there is a significant possibility that, actually, the percentages of men with life expectancies ≤10 years are higher and the percentage of men with a life expectancy > 10 years is lower.
If you boil this down to cost issues, the USPSTF guidance is probably saving the costs of something like 52 percent of 4.17 million PSA tests a year (i.e., 2.17 million PSA tests). Is this a good thing or a bad thing? No comment. A man who was turning 75 at his next birthday, and had a life expectancy at that time of 15+ years, might have a very strong opinion, however.
The “New” Prostate Cancer InfoLink will continue to take the position that the USPSTF guidelines make a good deal less sense than those proposed in the Iowa Consensus.