Original Investigation | Less Is More

Five-Year Downstream Outcomes Following Prostate-Specific Antigen Screening in Older Men

Louise C. Walter, MD; Kathy Z. Fung, MS; Katharine A. Kirby, MS; Ying Shi, PhD; Roxanne Espaldon, BA; Sarah O’Brien, MPH; Stephen J. Freedland, MD; Adam A. Powell, PhD, MBA; Richard M. Hoffman, MD, MPH
JAMA Intern Med. 2013;173(10):866-873. doi:10.1001/jamainternmed.2013.323.
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Importance Despite ongoing controversies surrounding prostate-specific antigen (PSA) screening, many men 65 years or older undergo screening. However, few data exist that quantify the chain of events following screening in clinical practice to better inform decisions.

Objective To quantify 5-year downstream outcomes following a PSA screening result exceeding 4.0 ng/mL in older men.

Design and Setting Longitudinal cohort study in the national Veterans Affairs health care system.

Participants In total, 295 645 men 65 years or older who underwent PSA screening in the Veterans Affairs health care system in 2003 and were followed up for 5 years using national Veterans Affairs and Medicare data.

Main Outcome Measures Among men whose index screening PSA level exceeded 4.0 ng/mL, we determined the number who underwent prostate biopsy, were diagnosed as having prostate cancer, were treated for prostate cancer, and were treated for prostate cancer and were alive at 5 years according to baseline characteristics. Biopsy and treatment complications were also assessed.

Results In total, 25 208 men (8.5%) had an index PSA level exceeding 4.0 ng/mL. During the 5-year follow-up period, 8313 men (33.0%) underwent at least 1 prostate biopsy, and 5220 men (62.8%) who underwent prostate biopsy were diagnosed as having prostate cancer, of whom 4284 (82.1%) were treated for prostate cancer. Performance of prostate biopsy decreased with advancing age and worsening comorbidity (P < .001), whereas the percentage treated for biopsy-detected cancer exceeded 75% even among men 85 years or older, those with a Charlson-Deyo Comorbidity Index of 3 or higher, and those having low-risk cancer. Among men with biopsy-detected cancer, the risk of death from non–prostate cancer causes increased with advancing age and worsening comorbidity (P < .001). In total, 468 men (5.6%) had complications within 7 days after prostate biopsy. Complications of prostate cancer treatment included new urinary incontinence in 584 men (13.6%) and new erectile dysfunction 588 men (13.7%).

Conclusions and Relevance Performance of prostate biopsy is uncommon in older men with abnormal screening PSA levels and decreases with advancing age and worsening comorbidity. However, once cancer is detected on biopsy, most men undergo immediate treatment regardless of advancing age, worsening comorbidity, or low-risk cancer. Understanding downstream outcomes in clinical practice should better inform individualized decisions among older men considering PSA screening.

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Figure 1. Exclusion criteria used to define the final cohort of older men who underwent a screening prostate-specific antigen (PSA) test in 2003 at a Veterans Affairs (VA) facility. *History was defined by searching VA and Medicare inpatient and outpatient claims and the VA Central Cancer Registry between January 1, 1999, and the date of the index PSA test in 2003. †Veterans Affairs and Medicare claims were used to exclude men with prostate symptoms during the 3 months before their index PSA test because this PSA result was considered a diagnostic test rather than a screening test. CPT indicates Current Procedural Terminology; ICD-9, International Classification of Diseases, Ninth Revision.

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Figure 2. Flowchart of the 5-year outcomes following a screening prostate-specific antigen (PSA) result exceeding 4.0 ng/mL (to convert PSA level to micrograms per liter, multiply by 1.0) in men 65 years or older. Boxes in bold are terminal boxes where men do not progress further down the flowchart. Men without a prostate biopsy who were diagnosed as having prostate cancer during the 5-year study period by transurethral resection of the prostate or who started hormone therapy without biopsy are included in the No prostate biopsy box.

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Figure 3. Effect of age and comorbidity on the likelihood of dying of non–prostate cancer causes within 5 years of screening among men with an index screening prostate-specific antigen result exceeding 4.0 ng/mL (to convert PSA level to micrograms per liter, multiply by 1.0) and biopsy-detected prostate cancer (n = 5220). Error bars represent 95% CIs.




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