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Study suggests prostate screening more harmful for elderly men

POSTED: August 13, 2008 5:01 a.m.

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You’d think that screening for cancer would always be beneficial. But in some cases, it may do more harm than good.

This week, the U.S. Preventive Services Task Force issued new guidelines on screening for prostate cancer. The federal panel recommended that doctors stop screening men ages 75 and older.

That’s because prostate cancer in older men tends to be slow-growing, and the patient is likely to die of some other cause long before he begins feeling any symptoms from the cancer.

Many doctors and patients already choose not to treat a nonaggressive cancer late in life. But this is the first time a medical advisory group has recommended to not even bother screening.

Angie Caton, an oncology nurse who conducts screenings for the Cancer Center at Northeast Georgia Medical Center, predicts the new guidelines will be welcomed by health care providers.

"That sounds like the way a lot of doctors already think," she said. "It makes sense, because prostate cancer tends to be be more aggressive in younger men."

Screening is usually done through a combination of two tests: a digital rectal exam and a PSA blood test, which measures the patient’s level of prostate-specific antigen.

The panel is now studying whether it would be worthwhile to lower the minimum screening age from 50 to 40.

"The question is, does testing PSA in the early stages save lives?" said Dr. Richard LoCicero, an oncologist with the Longstreet Clinic. "We probably won’t know that for a few more years."

The debate over when to start screening is similar to the situation with breast cancer. Because breast cancer is rare in young women, the original guidelines called for screening mammograms starting at age 50, unless the woman had a family history of the disease.

But now, the American Cancer Society recommends mammograms beginning at age 40, because breast cancer in younger women is more aggressive.

If the minimum age were dropped even lower, additional cases could be caught early. But at some point, the number of extra lives saved has to be balanced against the economic cost of screening larger numbers of people.

Screening older men for prostate cancer also may raise the cost of health care because it can lead to further testing and treatment that may not be necessary. As odd as it sounds, prostate cancer is sometimes a condition you can just live with.

"The majority of older men at autopsy have prostate cancer, but it’s clinically insignificant," said LoCicero.

If something abnormal is detected at screening, the next step is a biopsy to determine the type and stage of cancer.

And screening is not an exact science. Many older men have benign prostate enlargement, which can affect their PSA level. They may be needlessly subjected to a biopsy even though they have only a mild degree of cancer or no cancer at all.

Gainesville resident Hank Tanner, a prostate cancer survivor, said the biopsy can be an unpleasant experience.

"It’s very painful, even with topical anesthesia and sedation," he said. "You pass blood for days afterward, and it’s possible to get an infection (from the procedure)."

Tanner said he agrees with the new guidelines. "Only if you’re symptomatic does it make sense to treat (prostate cancer)," he said. "It’s a quality of life issue, especially at age 75. The treatment can have a lot of side effects."

Tanner was 52 when he was diagnosed in 2006, and he went through a debilitating course of surgery, radiation and hormone suppression therapy.

Some men also experience impotence or incontinence.

"I wouldn’t want to subject an elderly person to all of that," Tanner said.

After diagnosing prostate cancer in an older patient, many doctors choose an approach called "watchful waiting," in which they monitor the patient’s status but don’t initiate treatment unless the cancer gets worse.

But the tumor may remain unchanged for 10 years, and watchful waiting could create more stress for an elderly patient, causing him to worry needlessly.

LoCicero said it could be useful to put an upper age limit on screening. "Between 70 and 80, we had to start asking ourselves, does this make sense now?" he said. "We’ve always said that prostate cancer screening is sort of an informed discussion between the patient and his doctor about the pros and cons.

"The message (of the new guidelines) is that this is a screening test that needs to be individualized."

Medical providers emphasize that men of any age still can ask for a screening.

"I’m glad we now have some evidence to reassure older patients that they don’t have to be screened," said Caton. "But we have men come to our (free) screenings even in their 80s, and we won’t turn them away."



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