AUA 2013: AUA guide takes tailored approach to PCa screening

The AUA has released a PSA-focused, evidence-based guideline on early detection of prostate cancer that is intended to assist the urologist in advising an average-risk, asymptomatic man about prostate cancer screening, said H. Ballentine Carter, MD.

The new guideline marks a shift away from the one-sized-fits-all recommendations of other medical and public health groups and toward a targeted, personalized approach to screening.

Recognizing that the harm-to-benefit ratio of screening is highly dependent on age, the guideline panel developed its recommendations with men stratified into four age groups. The group determined that the greatest benefit of screening appears to be in men ages 55 to 69 years. For patients in this age group considering screening, the panel strongly recommended shared decision making between a patient and his physician and then proceeding based on a man’s values and preferences.

The guideline emphasizes that when discussing screening, patients should know that the benefit is preventing prostate cancer-related mortality in one man per 1,000 screened over a decade. This needs to be weighed against the known potential harms of screening and treatment.

According to the guideline, a routine screening interval of 2 years or more may be preferred over annual screening in order to reduce the harms of screening when a decision has been made to proceed. However, the rescreening interval may be individualized according to the baseline PSA level.

Outside of this age group, men younger than 55 years who are at higher than average risk for prostate cancer as well as some men over age 70 who are in excellent health may also benefit from screening. Decisions for these men should be individualized.

PSA screening is not recommended for men aged <40 years, according to the guidelines, which also recommend against routine PSA screening for men aged 40 to 54 years at average risk, men aged 70 years or more, and those with less than a 10- to 15-year life expectancy.

Dr. Carter, chair of the AUA’s Detection of Prostate Cancer Guideline Panel, emphasized that the guidelines were developed by a multidisciplinary panel that included representatives from radiation oncology, medical oncology, epidemiology, and general/internal medicine in addition to urologists. He also underscored that the guideline is very different from the Best Practice Statement on PSA that the AUA issued in 2009.

“The Best Practice Statement was an evaluation of PSA not only for detection of prostate cancer, but also for risk stratification and for the management of prostate cancer. This guideline is an evidence-based evaluation of prostate cancer detection in order to reduce prostate cancer mortality,” he explained.

“In addition, the Best Practice Statement did not involve a systematic literature review, and the recommendations were based in large part on clinical experience and expert opinion rather than evidence.”

David F. Penson, MD, AUA Health Policy Council chair, noted that in developing the new guideline, evidence was interpreted from the perspective of the individual. In that respect, it differs from the recommendation statement issued in 2012 by the U.S. Preventive Services Task Force (USPSTF) that considered the same evidence but from a public health perspective.

“The USPSTF recommendation is against routine PSA testing because the group felt the harms outweigh the benefits in the aggregate. Our opinion is that there are some benefits and harms, and it is up to the doctor and patient to make the informed decision together,” Dr. Penson said.