Medicare should stop paying for prostate cancer screening in men over age 75

The following op-ed was published on June 1st, 2011 in the New York Times’ Room for Debate blog.

Medicare should stop paying for prostate cancer screening in men over the age of 75.

You may be surprised to hear that, especially coming from a primary care doctor. But evidence is mounting that screening for prostate cancer is not only ineffective in older men, but may actually be harmful.

The cornerstone of prostate cancer screening involves measuring the prostate specific antigen, or P.S.A., in the blood. But the test is notoriously inaccurate and cannot differentiate between prostate cancers that are dangerous and ones that aren’t. It’s a crucial distinction, since most American men diagnosed with prostate cancer won’t die from it.

Studies have been inconclusive about whether prostate cancer screening saves lives. What’s more certain are the harmful effects, including impotence and urinary incontinence, caused by unnecessary prostate procedures stemming from false positive P.S.A. tests. The U.S. Preventive Services Task Force updated their prostate cancer screening guidelines in 2008, and after careful deliberation of the evidence, recommended against screening older men.

But those guidelines continue to be ignored. This past March, the Journal of Clinical Oncology found that nearly a quarter of men aged 85 and older continued to receive P.S.A. screening tests.

Why is this?

One reason is that Medicare pays for annual prostate cancer screening in all men 50 years and older, with no upper age limit.

Another is that drug companies market aggressively, and profit from, the treatments born from prostate cancer screening, whether necessary or not. In fact, Richard J. Ablin, the immunobiologist who discovered P.S.A. in 1970, called P.S.A. screening a “hugely expensive public health disaster.”

Dr. Kenneth Lin, lead author of the U.S. Preventive Services Task Force’s prostate cancer screening guidelines, also blames the news media. In an email to me, he said “news shows invariably feature athletic septuagenarians on the golf range telling reporters that they don’t want some government panel taking their P.S.A. tests away. But most 75-year-old men are in much poorer health, and prostate cancer surgery has no survival benefits in men over age 65, much less 75.

About $3 billion annually is spent on P.S.A. testing alone, with a substantial portion paid for by Medicare. An upper age limit on prostate cancer screening not only would shave those costs, but more important, spare patients from the harms of unneeded prostate procedures.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitter, and LinkedIn.

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  • http://www.twitter.com/sjdmd Steven J. Davidson, MD, MBA

    My vigorous, 79 year old physician-father saw patients, sailed, did home repairs and played with his grandkids; I don’t know his PSA, but 2-1/2 years later he was dead from his Gleason 9 metastatic prostate tumor.

    Having practiced medicine for >35 years I’ve found only child-rearing more humbling. Guidelines are good, I applaud them; physicians who consider deviations and act on that consideration should be encouraged to do so. Reducing, not eliminating, variation ought be the goal.

  • http://patientprivacyreview.blogspot.com/ Joel Sherman MD

    Having a strongly positive family history of prostate cancer, I will continue screening at any age as long as my general health warrants it.

    • Hospice and Palliative Care Doctor

      Esteemed colleague Dr. Sherman,

      Below is a portion of the USPSTF statement on PSA screening.
      “The USPSTF found convincing evidence that treatment for prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death. These harms are especially important because some men with prostate cancer who are treated would never have developed symptoms related to cancer during their lifetime.

      For men 75 years or older, there is moderate certainty that the harms of screening for prostate cancer outweigh the benefits. ”

      If you were with your PCP, and you responded with this s/he would say “I certainly understand your point, but I wonder if you could be more specific in your personal goals?”

      So, could you be more specific? What age would you stop? How do you respond to the statement with “moderate certainty the harms of screening for prostate cancer outweigh the benefits.”

      And that would be your personal health goal. As a physician, how would you counsel patients over 75 y/o given the clinical evidence as presented above?

      Warmest regards

      • http://patientprivacyreview.blogspot.com/ Joel Sherman MD

        General statistics don’t apply when you have strong risk factors such as 2 close relatives with metastatic prostate disease. A high PSA doesn’t necessitate proceeding to surgery, but it certainly is a marker for closer follow up. Ignoring high PSA’s certainly increases anyone’s risk.

        • Hospice and Palliative Care Doctor

          Dear Dr Sherman,

          Yes, risk factors should be a part of the discussion. But this article specifically addressed what age should PSA testing stop, even with those with risk factors. Could you utilize the data & address the question I posed to you which was to be more specific. What age would you end PSA testing for yourself? 75? 80? 85? or…?

          • http://patientprivacyreview.blogspot.com/ Joel Sherman MD

            Age is not relevant to me; it’s only a statistical guideline. I would want to be treated as an individual.
            I told you, I’d stop screening when my general health no longer warrants it. That could be age 60 or 90.

  • John Ryan

    So let me get this clear, there is a relatively cheap and safe lab test to tell older men if they may have cancer, which is rarely but sometimes aggressive. But let’s not let them know, they may make the wrong call. The USPHS knows better. A few will die, but we will save lots of money, and no one over age 75 will worry about an elevated PSA.

    They really don’t deserve to make that decision themselves. Professional arrogance?

    • Hexanchus

      John,

      The reality is that an elevated PSA level is not a reliable indication of the presence of prostate cancer. In fact, 65-75% of those biopsied due to a high PSA level do not have prostate cancer – that’s a huge false positive rate (see NCI web page for an excellent unbiased treatise on the accuracy and reliability of this test).

      As Kevin pointed out, studies have shown that use of the PSA test does not reduce the mortality rate. Bottom line, broad scale PSA screening is of questionable value, even in younger men. IMHO it’s better to focus screening resources on those with a known higher risk factors.

      • John Ryan

        It still takes the patient out of the discussion. I am both a patient and a physician, and that doesn’t make sense to me in either role.

  • Olesawbones

    The main issue here is that 75 is good in most, but not all men, as an upper limit. The AUA suggests that a 10 year life expectancy dictate the upper limit cutoff, and that patient-tailored approach makes more sense.

  • solo fp

    Should we extend this to mammograms, colonoscopies, prostate biopsies, dialysis, life support, and any cancer treatment to end at 75? Likely this would be a political nightmare with huge public outcry. The “death panels” claim would start again.
    I talk to my 75 or older males and give them the option on the PSA. I talk to them about what we would do with an elevated PSA. A lot of it depends on the patient. I h ave 90 year old males in great shape, driving their own cars and living in their own homes. I also have 75 year old males who are in nursing homes with end stage dementia who urologists still bring in for the PSA.

    • Hospice and Palliative Care Doctor

      So are you suggesting, and do you order PSA tests on your “90 year old males in great shape, driving their own cars and living in their own homes”?

  • Wesley Hard

    No insurance should cover PSA screening in men over 75. PSA screening has not been shown to extent life, even in men under 75. Men over 75 will just be harmed with unnecessary procedures if they are screened.

  • http://ethicalnag.org/2009/12/20/profit-before-patients/ Carolyn Thomas

    The Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial in the U.S. found the rate of death from prostate cancer was very low for both the 38,343 men in the group that received annual PSA-based screening and the 38,350 men in the control group who received “usual care.” Their conclusion:

    “Screening was associated with no reduction in prostate cancer mortality.”

    I recommend urologist Dr. Anthony Horan’s book “The Big Scare: The Business of Prostate Cancer”. Or the New York Times’ op ed piece by Dr. Richard J. Ablin, the inventor of the PSA test: “PSA Prostate Screening Is Inaccurate and a Waste of Money” – http://www.nytimes.com/2010/03/10/opinion/10Ablin.html?_r=1&emc=eta1

    Unfortunately, Dr. Kevin, I suspect that patients who hear the Big C word don’t care about things like low prostate cancer mortality rates when it’s their body you’re talking about.

  • http://retiredbicycle.blogspot.com Allison

    I can not tell you how angry this makes me. Does our value as a human being expire at 75? I ride bicycles with 75 year old men who can out climb many 20 year olds. Not every older man is infirm, and many can and would benefit from surgery. Should we just tell them too bad, so sad, now go die? This point of view is just stupid, and you should rethink.

    • Hospice and Palliative Care Doctor

      Dear Alison,
      Please, hold onto your emotions & look at this from a logical, compassionate, & scientific perspective.
      Below is a portion of the USPSTF statement on PSA screening.
      “The USPSTF found convincing evidence that treatment for prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death. These harms are especially important because some men with prostate cancer who are treated would never have developed symptoms related to cancer during their lifetime.

      For men 75 years or older, there is moderate certainty that the harms of screening for prostate cancer outweigh the benefits. ”

      The science does not support your comment of “many can and would benefit from surgery”.

      Rather, the science supports the view that testing either doesnt help, or HARMS. For example, here is risk of incontinence & fecal incontinence-have you ever seen a grown man wearing pull-ups? I have & it’s not pretty. There is risk of erectile dysfunction. Sex is really important to a vast majority of men & very possible for men to enjoy later in life but with PSA testing/treatment sex may not be possible, even with Viagra.

      Most important, Alison, there is risk of DEATH.

      These seem like very SERIOUS complications for a test with a high false positive rate & for a cancer unlikely to actually cause his death.

      Could you address my points?

      • John Ryan

        Typical straw man argument. Surgery is not the issue. There are many palliative methods with limited or no harm for local or metastatic disease. Real case, followed by residents in training program: older man with back & hip pain, probably just arthritis right? Xrays inconclusive (blastic changes are not always seen). Take some Advil, oh my, pathologic fracture, PSA after the fact — 40!. Well there goes the golf. But I guess he’ll just enjoy the rest of his days in hospice…

        • Hospice and Palliative Care Doctor

          Poor example. The PSA in your example, w subsequent prostate biopsy is not SCREENING in an asymptomatic patient, which is the topic of this article: screening every asymptomatic men above 75 for prostate CA. The guidelines by the USPSTF would not necessarily apply to your example.

          But I appreciate your participation in this difficult debate.

      • Olesawbones

        Sure, I’ll be happy to address some of them.

        1) Diagnosing prostate cancer does not equal treating it. Active surveillance and other protocols are in place to follow low aggressiveness cancers (ie, Gleason 6, low volume, low clinical stage) versus intermediate or higher risk cancers.

        2) Screening can save lives in population level models. Check out Swedish experience for one example.

        3) Again, not all 75 year olds are the same. Are you suggesting a 74 year 11 month old can be screened, but a 75 year 1 month old shouldn’t? Doesn’t make much sense? Follow a patient tailored approach (estimate life span by co-morbidity. . .the insurance companies do this all the time) and you can screen in a sensible way.

        4) The co-morbidities you mention are present, to be sure, but the only one that occurs in surgical patients to any clinically significant extent is ED. Full incontinence is rare. And other treatment options (radiation therapy, cryosurgery, etc.) may have fewer side effects. And remember, after proper counseling therapy can be instituted in only those men who have a significant risk of being affected by their prostate cancer.

        5) Finally, and again, PSA screening does not equal prostate cancer treatment. That is what discussion, education, etc. are for.

  • rich md

    unfortunately, it is easier to order psa every lab draw, and if psa >4 or velocity is high, turf to urology. there are plenty of urologists to see the patient, and they will be more than happy to do prostate biopsy x 3 (12 cores) or more “just to make sure”. the patient and their families will be grateful that you are “taking things seriously” and doing everything you can to help dad…this goes for any age. believe me, if a 89-year-old is told he has high psa and/or cancer from another doctor, you don’t want to be the “stupid pcp” who wasn’t checking psa…

    neither pcp’s nor urologists have time to explain the controversies of psa testing…even educated medical professionals cannot agree on this (see the numerous postings above mine)…
    the time it takes to order psa and if psa is high, refer to urology is less than 10 seconds.

    • John Ryan

      Speak for yourself. My patients won’t let me refer without a clear discussion. You do need to give them a) the option to get the test, and b) the time to discuss it. Very suitable office visit. Cannot understand why a doc wouldn’t.

      • Hexanchus

        John,

        I completely agree. Screening tests are optional, and have many potential ramifications – they should only be run with the informed consent of the patient after discussing both the pros & cons.

  • AnnR

    The phrase “Medicare will pay” seems to inspire seniors of America to feel that they must have whatever is available done.

    Should your elderly mother/father who has dementia and gets taken to the doctor for medication adjustments be screened for breast/prostrate cancer?

    If Medicare pays it becomes nearly an obligation for whoever is managing them to have the screening done. if Medicare doesn’t pay then it’s easier to let it go.

    • John Ryan

      I think the cliche of the demanding patient needs to be dispelled. If the patient has a request, provide them your expertise. Yes it takes time. May even take a complete visit (which insurance will pay). If they are irrational about it (a small minority) — find another doc please.

  • Doc 99

    Never tell a man w when he is going to die. He may live to p*$$ on your grave.

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    The problem is that there are numerous tests that Medicare pays for and seniors demand that are of questionable value. I shudder every time a patient with no family history of prostate cancer and a normal digital rectal exam demands that we send the test. If I take the time to explain the controversies it is most often greeted with a look that says ” hey guy my wife wants me to have the test and all my male friends at the club had no problem getting their doctor to order the test.”
    We could make a better case for the measurement of Vitamin D levels routinely as even more costly and controversial.
    Before we start forbidding payments for individual tests the federal government needs to put in its own secure computer payment infrastructure and take the job away from outsourced entities in each state. That way the fraud and abuse for true criminal claims could be eliminated before the government pays out millions of dollars to a firm that doesnt exist for goods that never existed

  • JPB

    One point that no one has made. Kevin was talking about Medicare paying for the test. If someone really wants the test and it isn’t covered, they can choose to pay for it themselves…

    • pj

      And that’s one reason why the US health care nonsystem is in such bad shape…

  • Anonymous

    Patients who request this test are analogous to those who request unnecessary antibiotics. The public good and the patient’s good demands time consuming education. However, it is so much quicker and easier to just fill out the order.

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