title: Five-year downstream outcomes following prostate-specific antigen screening in older men.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Longitudinal cohort study in the national Veterans Affairs health care system.
  
  
  METHODS
  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.
  
  
  METHODS
  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
  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.
authors.affiliation: Division of Geriatrics, San Francisco VA Medical Center, Mail Code 181G, 4150 Clement St, San Francisco, CA 94121, USA. Louise.Walter@ucsf.edu
authors.forename: Louise C
authors.initials: LC
authors.lastname: Walter
authors.forename: Kathy Z
authors.initials: KZ
authors.lastname: Fung
authors.forename: Katharine A
authors.initials: KA
authors.lastname: Kirby
authors.forename: Ying
authors.initials: Y
authors.lastname: Shi
authors.forename: Roxanne
authors.initials: R
authors.lastname: Espaldon
authors.forename: Sarah
authors.initials: S
authors.lastname: O'Brien
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Freedland
authors.forename: Adam A
authors.initials: AA
authors.lastname: Powell
authors.forename: Richard M
authors.initials: RM
authors.lastname: Hoffman
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D014408:Biomarkers, Tumor / Q000097:blood*; D001706:Biopsy; D015897:Comorbidity; D003657:Decision Making; D055088:Early Detection of Cancer / Q000009:adverse effects* / Q000379:methods / Q000592:standards; D007172:Erectile Dysfunction / Q000453:epidemiology / Q000209:etiology; D005189:False Positive Reactions; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008403:Mass Screening; D008498:Medical Record Linkage; D006278:Medicare; D057285:Precision Medicine; D017430:Prostate-Specific Antigen / Q000097:blood*; D011471:Prostatic Neoplasms / Q000175:diagnosis* / Q000276:immunology / Q000517:prevention & control / Q000628:therapy*; D018570:Risk Assessment; D012307:Risk Factors; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs; D019564:Unnecessary Procedures; D014549:Urinary Incontinence / Q000453:epidemiology / Q000209:etiology
chemical_list: D014408:Biomarkers, Tumor; D017430:Prostate-Specific Antigen