PSA Screening Among Elderly Men With Limited Life Expectancies

UroToday.com - PSA screening is recommended in men starting at age 50 (45 for positive family history or African-American race) and stopping when the life expectancy decreases to below 10 years. A report in JAMA from Dr. Walter and colleagues determined the PSA screening rates among elderly veterans stratified into subgroups based upon age and a validated measure of health status that is strongly predictive of life expectancy.

A cohort study was performed using data from the VA Automation Center. In addition, claims linked to Medicare claims from the VA Information Resource Center were analyzed. The final analysis was based upon a final screen-eligible cohort of 597,642 men.

To validate that PSA tests in the cohort were primarily sent for screening purposes, an audit from a random sample of 100 medical charts of men at the San Francisco VA was performed with 87% agreement. Age was categorized into 4 groups; 70-74 years, 75-79 years, 80-84 years, and 85 years and older. The Charlson Comorbidity Index defined health status, which is a measure of 19 chronic diseases selected and weighted according to their associations with mortality.

Median age was 77 years and median Charlson score was 1.8. Thirty percent of men had a Charlson score of 0 (best health) and 15% had a score of 4 or more (worst health). To put this in perspective, 47% of men in worst health had been hospitalized during one year compared to 6% in best health. A total of 56% of elderly men (333,041 of 597,642) received a PSA test in 2003. 68% of these had their first PSA performed in the VA system whereas 32% were performed within Medicare. Age was the strongest predictor of PSA screening. PSA screening decreased with increasing age; 64% for men aged 70-74 and 36% for men aged 85 years or older. Rates of PSA screening in the cohort did not decrease as much as estimated 10-year survival decreases with advancing age.

Although the an increase in Charlson score from 0 to 4 is associated with more than a 4-fold increased risk of death, worsening health was associated with only a small decrease in PSA screening rates. Within each age group, worsening health had little influence on PSA screening rates. For example, among men aged 85 years and older, the PSA screening rate for those in best health was 34% vs. 36% for men in worst health. Non-clinical factors such as marital status and region of the country were more predictive of PSA screening than health in multivariate analyses.

Men with a low probability of living 10 years were still likely to undergo PSA screening. This is exemplified by 36% of men aged 85 years or older being screened while less than 10% of men in the age group are expected to survive 10 years.

Louise C. Walter; Daniel Bertenthal; Karla Lindquist; Badrinath R. Konety
JAMA. 2006; 296 :2336-2342.

Reviewed by UroToday.com Contributing Editor Christopher P. Evans, MD

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