PSA dilemma for the elderly man

Recommendations to undergo annual PSA screening for men over 40 have resulted in cutting the mortality rate for prostate cancer by 50 percent.

Swedish research found that the reduction in the mortality of prostate cancer attributable to PSA screening exceeded the reduction in mortality for colorectal and breast cancer resulting from screening. However, this is not so simple for the elderly and it’s especially not so clear exactly how to define the term “elderly.”

Some groups consider those over 75 as being elderly and others consider the term should be reserved for those with a life expectancy of less than 10 years regardless of their chronological age. In this group, the dilemma becomes apparent because screening with annual PSA tests may actually have a more negative effect than a positive one. The explanation for this is that prostate cancer is often a slow growing malignancy that may take more than 10 years to become symptomatic.

Many elderly men die of some other condition before their prostate cancer threatens their life. Further, elevation of the PSA may lead to prostate biopsy and subsequent treatment possibly associated with adverse side effects such as incontinence and impotency, which certainly impair the quality of life.

Even if testing does reveal a cancer, particularly a low-grade cancer, active surveillance is now a way for the patient to be closely followed but treated only if there is evidence of progression of the disease.

Furthermore, new research at Johns Hopkins, appears to suggest that men whose cholesterol is controlled below 200 by the use of Statin drugs had a 60 percent reduction in risk of developing the most malignant type of prostate cancer.

The problem of distinguishing high grade clinically relevant cancers, whose potential to shorten the life of the patient or cause harm if not aggressively treated from the low grade indolent tumors best handled with active surveillance is under investigation.

One of the more interesting findings as reported in the New England Journal of Medicine was that the PSA of men who were given Dutasteride (Avodart) fell to about one half of their “Pre-Dutasteride” levels and rose thereafter if a high grade prostate cancer developed.

The PSA increase did not occur with more innocuous tumors, less likely to cause harm to the patient. This helps to separate the men into those who would benefit from early diagnosis and aggressive therapy from those best treated with continued active surveillance.

The final piece of the puzzle is to determine the appropriate PSA trigger point to decide when a patient, especially an elderly patient, who has been under active surveillance should be aggressively treated. This is now under active research and no firm conclusions have yet been reached. The best and wisest thing to do is discuss your individual situation with own doctor.

Have a question? Call Dr. Okun at 718-241-6767

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