DEAR DR. ROACH: I’m writing to you about an elderly patient who is currently 96 years old. For the last three years, his PSA score for his prostate has hovered around 30 ng/ml. He initially received an ultrasound and was determined that the prostate looked normal, despite the high PSA score. The general physician, under the following circumstance, referred the patient to a urologist. Subsequently, the urologist wrote back saying he would not be taking the patient due to age and that he would not be accepting any future requests.
More recently, due to a routine physical checkup, the PSA score is now at 105. The physician, thinking it might be a case of inflammation of the prostate, prescribed one month of antibiotics. It didn’t seem to assist the issue, and now the most recent PSA score is 207. The patient was told, due to the previous response from the urologist two years ago, that no further action should be taken, although it is now suspected that the patient has prostate cancer.
Although my family has an understanding that, because of the patient’s age, it might be in his best interest to not receive any treatment for suspected prostate cancer, we are wondering if this kind of a response from a urologist is actually appropriate. The patient has asked for a referral to another urologist, but was told they belong to a group of urologists in the nearest city and that this is their protocol.
Perhaps, it is the bluntness of the letter from the urologist to the physician, but we are finding it a hard pill to swallow that, in this circumstance, a urologist has already predetermined that someone shouldn’t receive treatment and that it’s not up to the patient to decide. Is this what happens to elderly patients? — D.
ANSWER: This shouldn’t be what happens to anyone.
Screening for prostate cancer is not appropriate for a person in their 90s, since more men will be harmed than men who will receive benefit from treatment, and I suspect that is what the urologist used to make their decision. Screening, by definition, is when the person has no symptoms. Sometimes, a person comes to me already with the results of a test I wouldn’t have ordered, but it’s irrational to pretend you don’t have the information. You do, and now, a rational decision needs to be made.
The higher the PSA score, the greater the likelihood of the person having prostate cancer. I have never seen a PSA level above 100 where the man did not have advanced prostate cancer, and this is confirmed by observational studies. At a level of greater than 200, it is very likely that the prostate cancer has spread outside the prostate to local lymph nodes, or even to the bones.
A universal refusal to see a patient beyond a certain age is not medically appropriate. A physician cannot make an informed judgment without attending the patient. It may indeed be the case that no treatment is indicated. However, there are treatments that can improve the quality of life in most men with advanced prostate cancer (if that’s what he has — the ultrasound alone doesn’t give the diagnosis). It is impossible to decide what is right without knowing more.
As a primary care doctor myself, I empathize with his general physician, who wants to help and is doing their best. But we are not trained to treat advanced prostate cancer, and I don’t think the phyisican has enough information to make a treatment recommendation.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to [email protected] or send mail to 628 Virginia Dr., Orlando, FL 32803.
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