Health

Too Many Older Men Are Still Screened for Prostate Cancer

Last summer, Joe Loree made an appointment with a urologist. He occasionally noticed blood in his urine, which he wanted to have examined. His doctor ordered a prostate-specific antigen (PSA) test to measure a protein in his blood that could indicate prostate cancer or other benign conditions.

“We’re back at a somewhat high price,” said Laurie, 68, an instructional designer in Berkeley, Calif.

Loree’s risk was very low, but nobody likes hearing the C word. “It’s disturbing to think that I have cancer growing inside of me,” he said.

But his brother and friend were both diagnosed with prostate cancer and were undergoing aggressive treatment he hoped to avoid, so a more conservative approach called active surveillance reassured Rory.

This usually means regular PSA evaluations and biopsies, often with MRIs and other tests, to monitor for signs that the cancer may be progressing. He hasn’t, so now he can take the PSA test every 6 months instead of every 3 months.

Studies show that an increasing proportion of men with low-risk prostate cancer are opting for aggressive surveillance. Medical guidelines now recommend.

Diagnosis was directly linked to aggressive treatment. As recently as 2010, he noted that about 90% of men with low-risk prostate cancer had immediate surgery to remove the prostate (prostatectomy) or radiation, sometimes with hormone therapy. rice field.

However, between 2014 and 2021, Increased proportion of men at low cancer risk opting for active surveillance A study using data from the American Urological Association National Registry increased from about 27% to about 60%.

Matthew Cooperberg, Ph.D., urological oncologist at the University of California, San Francisco, and lead author of the study, said:

Changes in medical practice often take a frustratingly long time. In this study, his 40% of men with low-risk prostate cancer were still receiving invasive treatment. And approaches vary greatly between urological practices.

The percentage of men under active surveillance “ranges from 0% to 100%, depending on which urologist they happen to see,” Dr. Cooperberg said. “Ridiculous”

latest results of large UK study, recently published in the New England Journal of Medicine, provides additional support for surveillance. Between 1999 and 2009, researchers followed her more than 1,600 men with localized prostate cancer who underwent active monitoring, prostatectomy, or radiation therapy with hormone therapy.

With a very long follow-up of an average of 15 years, less than 3% of men with an average age of 62 years at diagnosis died from prostate cancer. Differences among the three treatment groups were not statistically significant.

Cancers in the surveillance group were more likely to metastasize, but this did not lead to increased mortality. “The benefit of treatment in this population is not clear,” says Mayo, an oncologist at the clinic who specializes in prostate cancer. Editorial accompanying the study.

“It doesn’t help people live longer,” Dr. Sartor said of the treatment.

Men whose PSA levels or other test results indicate a high-risk tumor, or who have a family history of death from prostate cancer, fall into a separate category, experts warn.

“The point of screening is to find aggressive tumors, which are in the minority but kill more people than any other cancer except lung cancer,” Dr. Cooperberg said.

But most prostate cancers, if they do, grow very slowly, so other diseases are more likely to prove fatal first, especially in older men. In , 1 in 5 men died from other causes, mainly cardiovascular and respiratory diseases and other cancers.

for that reason, U.S. Preventive Services Task Force and the American Medical Association Men over the age of 69 or 70, or with a life expectancy of less than 10 to 15 years, are advised against regular prostate cancer screening. (He recommends that men ages 55 to 69 discuss the harms and benefits with their health care provider before deciding to undergo screening.)

newly revised American Urological Association Guidelines Given age, life expectancy, other risk factors, and patient preferences, we recommend shared decision-making after age 69.

“If you live long enough, prostate cancer is a nearly normal feature of aging,” explained Dr. Cooperberg. I have.”

Most of these tumors are considered “indolent”. This means that the tumor will not spread or cause any troublesome symptoms.

Still not About half of men over 70 years old continue PSA screening, according to a new study in JAMA Network Open. Testing has declined with age, but “you shouldn’t be getting tested at this rate,” says lead author Sandhya Kalavacherla, who is a medical student at the University of California, San Diego.

About 40% of men over the age of 80 had regular PSA tests. An elevated PSA level may prompt a series of subsequent tests and treatments. This is because “‘cancer’ is an emotional term,” admitted Dr. Sartor. He said he still sees patients whose response to very low-risk cancer is “I want to end it now.”

However, treatment is associated with significant side effects that often subside in the first year or two, but can persist or even worsen. For example, the UK data are 6 months after treatmenturine leakage requiring pads affected about half of men who had prostatectomy, compared with 5% of men who had radiation and 4% of men who were under active surveillance. rice field.

After 6 years, 17% of the prostatectomy group still needed pads. Among those under active surveillance, it was 8 percent and 4 percent in the radiation group.

Similarly, men under active surveillance were more likely to maintain erectile capacity, but all three groups reported decreased sexual function with age. 12 years later Men in the radiation group were twice as likely (12%) to report fecal leakage than men in the other groups.

The economic costs of unnecessary tests and treatments are also high, as an analysis of claims from the large Medicare Advantage program shows. This research was recently presented at the JAMA Network Open. saw the payment Routine PSA screening and related services for men age 70 and older with no pre-existing prostate problems.

“Unnecessary initial screenings trigger these follow-up services, a chain of events catalyzed by anxiety,” said David Kim, a health economist at the University of Chicago and lead author of the study. The more you progress, the harder it will be to stop.”

From 2016 to 2018, for every $1 spent on PSA testing in men over 70, another $6 was spent on additional PSA testing, imaging, radiology and surgery.

Applied to traditional Medicare beneficiaries, Medicare may have spent $46 million on PSA testing for men over 70 and $275 million on follow-up care, Dr. Kim said.

“We need to change the incentives, the way providers are paid,” he said.

He said refusing reimbursement for less-recommended procedures from the U.S. Preventive Services Task Force could mean fewer inadequate PSA tests followed by less aggressive treatment. suggested.

Some urologists and oncologists want a different kind of shift. Nomenclature. “Why call it ‘cancer’ in the first place?” asked Dr. Sarter. objected to the use of the word For small, low-risk tumors of the prostate.

A less terrifying label — indolent lesions of epithelial origin, or IDLE, was one suggestion — would make patients less likely to view test results as harbingers of fatality, potentially leading to the operating room or never to radiotherapy. It can motivate you to carefully track certain general conditions. center.

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