Five-Year Downstream Outcomes Following Prostate-Specific Antigen Screening in Older Men | Cancer Screening, Prevention, Control | JAMA Internal Medicine | JAMA Network
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Moyer VA.U.S. Preventive Services Task Force.  Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement.  Ann Intern Med. 2012;157(2):120-13422801674PubMedGoogle ScholarCrossref
Smith RA, Cokkinides V, Brooks D, Saslow D, Shah M, Brawley OW. Cancer screening in the United States, 2011: a review of current American Cancer Society guidelines and issues in cancer screening.  CA Cancer J Clin. 2011;61(1):8-3021205832PubMedGoogle ScholarCrossref
Greene KL, Albertsen PC, Babaian RJ,  et al.  Prostate specific antigen best practice statement: 2009 update.  J Urol. 2009;182(5):2232-224119781717PubMedGoogle ScholarCrossref
Walter LC, Bertenthal D, Lindquist K, Konety BR. PSA screening among elderly men with limited life expectancies.  JAMA. 2006;296(19):2336-234217105796PubMedGoogle ScholarCrossref
Bynum J, Song Y, Fisher E. Variation in prostate-specific antigen screening in men aged 80 and older in fee-for-service Medicare.  J Am Geriatr Soc. 2010;58(4):674-68020345867PubMedGoogle ScholarCrossref
Drazer MW, Huo D, Schonberg MA, Razmaria A, Eggener SE. Population-based patterns and predictors of prostate-specific antigen screening among older men in the United States.  J Clin Oncol. 2011;29(13):1736-174321444863PubMedGoogle ScholarCrossref
Pollack CE, Platz EA, Bhavsar NA,  et al.  Primary care providers' perspectives on discontinuing prostate cancer screening.  Cancer. 2012;118(22):5518-552422517310PubMedGoogle ScholarCrossref
Prasad SM, Drazer MW, Huo D, Hu JC, Eggener SE. 2008 US Preventive Services Task Force recommendations and prostate cancer screening rates.  JAMA. 2012;307(16):1692-169422535850PubMedGoogle ScholarCrossref
Catalona WJ, D’Amico AV, Fitzgibbons WF,  et al.  What the U.S. Preventive Services Task Force missed in its prostate cancer screening recommendation.  Ann Intern Med. 2012;157(2):137-138Google ScholarCrossref
Miller DC, Hollenbeck BK. Missing the mark on prostate-specific antigen screening.  JAMA. 2011;306(24):2719-272022203542PubMedGoogle ScholarCrossref
Volk RJ, Wolf AMD. Grading the new US Preventive Services Task Force prostate cancer screening recommendation.  JAMA. 2011;306(24):2715-271622203540PubMedGoogle ScholarCrossref
Schröder FH, Hugosson J, Roobol MJ,  et al; ERSPC Investigators.  Prostate-cancer mortality at 11 years of follow-up.  N Engl J Med. 2012;366(11):981-99022417251PubMedGoogle ScholarCrossref
Andriole GL, Crawford ED, Grubb RL III,  et al; PLCO Project Team.  Prostate cancer screening in the randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: mortality results after 13 years of follow-up.  J Natl Cancer Inst. 2012;104(2):125-13222228146PubMedGoogle ScholarCrossref
VA Information Resource Center (VIReC).  VIReC Research User Guide: Fiscal Year 2009 VHA Medical SAS Inpatient DatasetsHines, IL: VA Information Resource Center, Health Services Research and Development Service, US Dept of Veterans Affairs. April 2011. Accessed February 25, 2013
VA Information Resource Center (VIReC).  VIReC Research User Guide: VHA Decision Support System: Clinical National Data Extracts2nd ed. Hines, IL: VA Information Resource Center, Health Services Research and Development Service, US Dept of Veterans Affairs. September 1, 2009. Accessed February 25, 2013
Hynes DM, Koelling K, Stroupe KT,  et al.  Veterans' access to and use of Medicare and Veterans Affairs health care.  Med Care. 2007;45(3):214-22317304078PubMedGoogle ScholarCrossref
Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.  J Clin Epidemiol. 1992;45(6):613-6191607900PubMedGoogle ScholarCrossref
US Census Bureau.  Summary file 3: 2000 census of population and housing. 2002. Accessed February 25, 2013
Welch HG, Schwartz LM, Woloshin S. Prostate-specific antigen levels in the United States: implications of various definitions for abnormal.  J Natl Cancer Inst. 2005;97(15):1132-113716077071PubMedGoogle ScholarCrossref
Merrill RM, Feuer EJ, Warren JL, Schussler N, Stephenson RA. Role of transurethral resection of the prostate in population-based prostate cancer incidence rates.  Am J Epidemiol. 1999;150(8):848-86010522656PubMedGoogle ScholarCrossref
Keating NL, Landrum MB, Lamont EB,  et al.  Quality of care for older patients with cancer in the Veterans Health Administration versus the private sector: a cohort study.  Ann Intern Med. 2011;154(11):727-73621646556PubMedGoogle ScholarCrossref
Howrey BT, Kuo YF, Lin YL, Goodwin JS. The impact of PSA screening on prostate cancer mortality and overdiagnosis of prostate cancer in the United States.  J Gerontol A Biol Sci Med Sci. 2013;68(1):56-61Google ScholarCrossref
McClish DK, Penberthy L, Whittemore M,  et al.  Ability of Medicare claims data and cancer registries to identify cancer cases and treatment.  Am J Epidemiol. 1997;145(3):227-2339012595PubMedGoogle ScholarCrossref
VA Information Resource Center.  VIReC Research User Guide: VHA Pharmacy Prescription Data2nd ed. Hines, IL: Health Services Research and Development Service, US Dept of Veterans Affairs. September 1, 2008. Accessed July 17, 2012
Sohn MW, Arnold N, Maynard C, Hynes DM. Accuracy and completeness of mortality data in the Department of Veterans Affairs.  Popul Health Metr. 2006;4:e2 Accessed February 20, 201316606453PubMedGoogle ScholarCrossref
Lin K, Lipsitz R, Miller T, Janakiraman S.U.S. Preventive Services Task Force.  Benefits and harms of prostate-specific antigen screening for prostate cancer: an evidence update for the U.S. Preventive Services Task Force.  Ann Intern Med. 2008;149(3):192-19918678846PubMedGoogle ScholarCrossref
Rosario DJ, Lane JA, Metcalfe C,  et al.  Short term outcomes of prostate biopsy in men tested for cancer by prostate specific antigen: prospective evaluation within ProtecT study.  BMJ. 2012;344:d7894 Accessed February 25, 2013Google ScholarCrossref
Nam RK, Saskin R, Lee Y,  et al.  Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy.  J Urol. 2010;183(3):963-96820089283PubMedGoogle ScholarCrossref
Taylor KL, Luta G, Miller AB,  et al.  Long-term disease-specific functioning among prostate cancer survivors and noncancer controls in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial.  J Clin Oncol. 2012;30(22):2768-2775Google ScholarCrossref
Potosky AL, Warren JL, Riedel ER, Klabunde CN, Earle CC, Begg CB. Measuring complications of cancer treatment using the SEER-Medicare data.  Med Care. 2002;40(8):(suppl)  IV-62-IV-6812187170PubMedGoogle Scholar
Daskivich TJ, Chamie K, Kwan L,  et al.  Overtreatment of men with low-risk prostate cancer and significant comorbidity.  Cancer. 2011;117(10):2058-206621523717PubMedGoogle ScholarCrossref
Andriole GL, Levin DL, Crawford D,  et al.  Prostate cancer screening in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial: findings from the initial screening round of a randomized trial.  J Natl Cancer Inst. 2005;97:433-438Google ScholarCrossref
Morgan TO, Jacobsen SJ, McCarthy WF, Jacobson DJ, McLeod DG, Moul JW. Age-specific reference ranges for prostate-specific antigen in black men.  N Engl J Med. 1996;335(5):304-3108663870PubMedGoogle ScholarCrossref
Welch HG, Fisher ES, Gottlieb DJ, Barry MJ. Detection of prostate cancer via biopsy in the Medicare-SEER population during the PSA era.  J Natl Cancer Inst. 2007;99(18):1395-140017848671PubMedGoogle ScholarCrossref
Schröder FH, Hugosson J, Roobol MJ,  et al; ERSPC Investigators.  Screening and prostate-cancer mortality in a randomized European study.  N Engl J Med. 2009;360(13):1320-132819297566PubMedGoogle ScholarCrossref
Grubb RL III, Pinsky PF, Greenlee RT,  et al.  Prostate cancer screening in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: update on findings from the initial four rounds of screening in a randomized trial.  BJU Int. 2008;102(11):1524-153019035857PubMedGoogle ScholarCrossref
Zeliadt SB, Buist DSM, Reid RJ, Grossman DC, Ma J, Etzioni R. Biopsy follow-up of prostate-specific antigen tests.  Am J Prev Med. 2012;42(1):37-4322176844PubMedGoogle ScholarCrossref
Cooperberg MR, Broering JM, Carroll PR. Time trends and local variation in primary treatment of localized prostate cancer.  J Clin Oncol. 2010;28(7):1117-112320124165PubMedGoogle ScholarCrossref
Boevee SJ, Venderbos LDF, Tammela TLJ,  et al.  Change of tumour characteristics and treatment over time in both arms of the European Randomized Study of Screening for Prostate Cancer.  Eur J Cancer. 2010;46(17):3082-308921047590PubMedGoogle ScholarCrossref
Chou R, LeFevre ML. Prostate cancer screening: the evidence, the recommendations, and the clinical implications.  JAMA. 2011;306(24):2721-272222203543PubMedGoogle ScholarCrossref
Carroll PR. Early stage prostate cancer: do we have a problem with over-detection, overtreatment or both?  J Urol. 2005;173(4):1061-106215758699PubMedGoogle ScholarCrossref
Wilt TJ, Brawer MK, Jones KM,  et al; Prostate Cancer Intervention Versus Observation Trial (PIVOT) Study Group.  Radical prostatectomy versus observation for localized prostate cancer [published correction appears in N Engl J Med. 2012;367(6):582].  N Engl J Med. 2012;367(3):203-21322808955PubMedGoogle ScholarCrossref
Bill-Axelson A, Holmberg L, Ruutu M,  et al; SPCG-4 Investigators.  Radical prostatectomy versus watchful waiting in early prostate cancer.  N Engl J Med. 2011;364(18):1708-171721542742PubMedGoogle ScholarCrossref
Draisma G, Etzioni R, Tsodikov A,  et al.  Lead time and overdiagnosis in prostate-specific antigen screening: importance of methods and context.  J Natl Cancer Inst. 2009;101(6):374-38319276453PubMedGoogle ScholarCrossref
Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer.  JAMA. 2009;302(15):1685-169219843904PubMedGoogle ScholarCrossref
Johansson E, Steineck G, Holmberg L,  et al; SPCG-4 Investigators.  Long-term quality-of-life outcomes after radical prostatectomy or watchful waiting: the Scandinavian Prostate Cancer Group-4 randomised trial.  Lancet Oncol. 2011;12(9):891-89921821474PubMedGoogle ScholarCrossref
Wilt TJ, MacDonald R, Rutks I, Shamliyan TA, Taylor BC, Kane RL. Systematic review: comparative effectiveness and harms of treatments for clinically localized prostate cancer.  Ann Intern Med. 2008;148(6):435-44818252677PubMedGoogle ScholarCrossref
Abd TT, Goodman M, Hall J,  et al.  Comparison of 12-core versus 8-core prostate biopsy: multivariate analysis of large series of US veterans.  Urology. 2011;77(3):541-54720817273PubMedGoogle ScholarCrossref
Original Investigation
Less Is More
May 27, 2013

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

Author Affiliations

Author Affiliations: Division of Geriatrics, San Francisco Veterans Affairs (VA) Medical Center and University of California, San Francisco (Drs Walter and Shi and Mss Fung, Kirby, Espaldon, and O’Brien); Durham VA Medical Center and Duke Prostate Center, Duke University, Durham, North Carolina (Dr Freedland); Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, and Department of Medicine, University of Minnesota, Minneapolis (Dr Powell); and New Mexico VA Health Care System and Department of Medicine, University of New Mexico, Albuquerque (Dr Hoffman).

JAMA Intern Med. 2013;173(10):866-873. doi:10.1001/jamainternmed.2013.323

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.