How did the American Urological Association handle the release of its new PSA guideline?

Dr. Kim“The AUA meeting was a good time to release the new guidelines-a large group of urologists were in one place with a venue to discuss the changes and explain them. However, in talking to some of my colleagues at the meeting, the guidelines did catch them off guard. Many of us did not know the guidelines were coming, and we were not aware of any opportunity for the public to comment on a draft version of the guideline. We have referring doctors and patients turning to us for our opinion, and we have to be able to explain the AUA position as well as the positions of the U.S. Preventive Services Task Force and the American College of Surgeons. You have groups on both sides of the fence.

I think the updated AUA guidelines better reflect the clinical trials that have been conducted on screening. Screening a narrower age range and PSA testing every other year is going in the right direction. Overall health and life expectancy might trump physiological age in deciding who benefits most from screening, but the narrower age range reflects that PSA-based screening for prostate cancer may not be as beneficial as we initially believed.

The 50-year-old clearly has the most to benefit by having a lethal prostate cancer diagnosed and treated, but prostate cancer is extremely rare in that age group, and our test can’t discriminate well between the indolent and potentially lethal cancers.”

Hyung Kim, MD

Los Angeles

“The AUA was getting a lot of pressure to step back from aggressive screening and treatment. For many of us in the urologic community, the AUA’s change in position was not much of a surprise because it confirmed what many of us feel. There is a time and a place for the PSA. It is not perfect, but it’s the best we have. It improves morbidity and mortality from prostate cancer.

There is a trade-off in unnecessary diagnosis, biopsies, and treatment, but the flip side is, it has to be used judiciously. Everybody shouldn’t get a PSA every few months, have multiple biopsies, and get surgery or radiation. You have to stratify patients based on risk, age, comorbidities, and life expectancy in general to show benefit. Conflicting data has come out in recent studies. I’m comfortable with the condensed targeted population because the goal is to offer screening to patients who will benefit; it’s sensible to offer the test to a group of people who will be at highest risk.

As a result, will there be people who may not be diagnosed with early prostate cancer? Sure, but it will cut back on the number of people who are screened and avoid potentially unnecessary treatments. The trade-off will be that the pendulum will swing the other way and we may see an increase in the number of patients diagnosed with metastatic disease. Eventually, we’ll get a better diagnostic tool that will better predict who should be biopsied and treated. We’re not there yet, but we’re not too far away.”

Tim Roytman, MD

Honolulu

“Our group all felt that we were caught off guard. Since we started doing PSA screenings in the early ‘90s, we know we’ve seen a steady decline of about 40% in prostate cancer deaths, so we’re all strong proponents of PSA screening.

The conversation gets mixed up between screening and treatment. There is a whole discussion about whether certain cancers in certain age groups should not be treated, and the answer is yes, but that doesn’t have anything to do with screening. You have to screen and detect cancer; then you can discuss whether the cancer should be treated.

Limiting routine screening to the ages of 55-69 creates two problems. If a person has prostate cancer at age 45, they will still have it at 55, but prostate cancer is most curable when treated early. So we believe in screening men at earlier ages. At the other end, if a man in his early 70s is in good health and has relatives in their 90s, we don’t agree we should tell that man not to bother checking for high-risk cancer that could potentially be treated.

We’ve had a number of young, white, low-risk males that have aggressive cancers in their 40s. If you wait until that man is 55, you’re going to miss that window to cure that individual. You will also find low-grade, low-volume cancers, but once they’re detected, you can discuss whether or not they should be treated.

Before we started screening, 77% of the guys who popped into our office with prostate cancer already had metastatic disease; the majority were non-curable. This could happen again.”

Eddie Bugg, MD

Birmingham, AL