Task force sets preventive screening guidelines

Q: I am 69 years old, in very good health and have a physical every year. Last year, my doctor of 20 years did not order a PSA test for prostate, even though it's covered by Medicare. Is a PSA test for a man my age necessary? My doctor has also stopped EKGs and chest X-rays. I'm confused.

A: You're bumping up against two issues here. One pertains to PSA screenings in particular, and the other concerns preventive screening tests in general. Let's take them in order.

For those who aren't familiar, a PSA test measures blood levels of a certain protein known as prostate-specific antigen. It is produced by both normal and malignant cells in the prostate. While high levels of PSA circulating in the blood can suggest the presence of cancer, that's not the only possible cause. Someone with an enlarged or inflamed prostate can also have a high result on a PSA test.

Each of those changes to the prostate gland become increasingly common as men reach older age, and they can lead to a false positive test result for cancer. This, in turn, can open the door to unnecessary additional tests and procedures, including a biopsy of the prostate gland.

Due to the complexities of accurately assessing a high PSA result, guidance regarding the test has evolved. As of 2018, the United States Preventive Services Task Force recommends its use in men between the ages of 55 and 69 be based on professional judgment regarding each man's risk factors, and also patient preference. The test is not recommended after age 70.

Prostate cancer tends to grow slowly. When identified in older age, an approach known as active surveillance, in which low-risk cancers are closely monitored, is often recommended.

And this brings us to the topic of preventive health screening guidelines. They are set forth by the United States Preventive Services Task Force, an independent panel of 16 volunteers who have expertise in primary health care and preventive care.

Among their mandates is the review of statistical data gathered in population-based health care studies, which follow large groups of people over the course of many years. The panel analyzes data collected in these studies. This includes preventive screening, onset of disease and outcomes. Using this detailed information, the panel assesses the efficacy of preventive health screening and proposes guidelines based on approaches that yielded the best results.

While these screening guidelines are useful, they are not the last word on the matter. In fact, some medical groups, including the American Cancer Society, sometimes disagree with the task force findings. When this occurs, they offer screening guidelines of their own. Not surprisingly, this leads to inconsistencies. The conflicting recommendations can leave patients not only confused, but at odds with their doctors.

In our own practices, we emphasize to our patients that screening guidelines are simply a tool, and not a set rule. Whether to move forward with any particular test is based on family and medical history, existing risk factors and input from the patients themselves.

Nonoperative management of appendicitis

Q: One of my roommates went to the ER because of abdominal pain and nausea. It turned out to be appendicitis, and we all thought he would need to have surgery. But the doctors did something they called nonoperative management, and he got better. What is that? Is it safe?

A: Let's start with the appendix. It's a small, thin pouch that extends from the juncture where the small and large intestines meet. In adults, it ranges from 2 to 4 inches long.

The appendix has long been categorized as a vestigial organ with no known function. However, newer research suggests it may play an important role in safeguarding populations of good bacteria during periods of intestinal illness.

When someone has appendicitis, it means their appendix has become inflamed. Symptoms often begin with the abdominal pain your roommate experienced. The classic presentation is pain in the center of the abdomen which, as it worsens, migrates to the lower right quadrant of the abdomen. This may be accompanied by loss of appetite, nausea, fever and something known as rebound tenderness - pain that occurs when pressure that has been applied to the abdomen is suddenly released. Coughing, walking or raising the right leg may also trigger pain during appendicitis.

Because of the variable position of each person's appendix, and the general nature of the symptoms, an accurate diagnosis of appendicitis can be challenging. Statistics show that one-fifth of cases are misdiagnosed. However, if an infected appendix ruptures, it will spill its toxic contents into the abdominal cavity. This is extremely dangerous. A burst appendix can lead to widespread, and often life-threatening, infection. But surgery also carries risk.

For that reason, and under certain circumstances, a medical team will opt for what is known as nonoperative management of appendicitis. This is an approach that does not include the removal of the appendix. It is used only in cases where scans and tests show that the appendix is not perforated, does not contain an abscess and is not at risk of rupture.

Instead of surgery, patients are treated with antibiotics to manage infection. This typically begins with several days of intravenous antibiotics, followed by up to a week or more of oral antibiotics. Some studies have found that managing the symptoms of inflammation without the use of antibiotics can be equally effective for certain patients.

While avoiding surgery is a plus, patients are left with a degree of uncertainty. The data show that some people with appendicitis who have nonoperative treatment go on to develop new symptoms. And the chance of a recurrence increases with time. A study that followed 257 of these patients found that, at the one-year mark, the incidence of recurrence was slightly more than 27%. By year five, it had risen to 40%. The return of symptoms meant additional emergency room visits, repeat hospitalization and, possibly, surgery. Your roommate's doctors will have advised him of this and given him instructions about what symptoms to watch for and how to respond should they arise.

• Dr. Eve Glazier is an internist and associate professor of medicine at UCLA Health. Dr. Elizabeth Ko is an internist and assistant professor of medicine at UCLA Health. Send your questions to askthedoctors@mednet.ucla.edu.