Prostate cancer screening guideline: Shared decision making key

San Diego-A new AUA guideline on the early detection of prostate cancer is a PSA-focused, evidence-based guideline intended to assist the urologist in advising an average-risk, asymptomatic man about prostate cancer screening in order to reduce prostate cancer mortality, said H. Ballentine Carter, MD, at the AUA annual meeting in San Diego.

“There are some people who may interpret this guideline as abandoning PSA screening. However, the panel feels

Dr. Carterit is the beginning of the initial stages of an approach to present an evidence-based, smarter screening strategy that targets the men most likely to benefit and improves the ratio of benefit to harm,” said Dr. Carter, chair of the panel for this guideline.

The guideline was developed by a multidisciplinary panel that conducted a systematic review of relevant studies published between January 1995 and February 2013. In formulating the guideline statements, the panel used the perspective of the individual and did not go beyond the evidence, stated Dr. Carter, director of adult urology at Brady Urological Institute and professor of urology and oncology at Johns Hopkins Medical Institutions, Baltimore.

Recognizing that the benefit:harm ratio of screening is highly age dependent, the guideline statements were developed with men stratified into four age groups (<40 years, 40-54 years, 55-69 years, and 70+ years). The panel identified men aged 55-69 years as the “target group” for which there is the most evidence for a screening benefit. For men in this age bracket considering screening, the guideline recommends shared decision making and proceeding based on a patient’s values and preferences.

“The guideline emphasizes shared decision making that should include a discussion of the man’s life expectancy and prostate cancer risk based on race and family history and the degree to which it might influence this risk,” said Dr. Carter.

“The decision to undergo screening must weigh the benefit of preventing one prostate cancer-related mortality per 1,000 men screened over a decade against the known potential harms of screening and treatment.”

Rescreening intervals can be individualized

The guideline panel also felt it was possible to reduce the harms of screening for men aged 55-69 years. Based on modeling studies, the guideline states that a routine screening interval of 2 years or more may be preferred over annual screening and that the rescreening interval may be individualized according to the baseline PSA level and/or prior PSA history.

Outside of the target age group, the guideline states PSA screening is not recommended for men aged <40 years, and it recommends against routine PSA screening for men aged 40-54 years who are at average risk, men 70 years of age and older, and those with less than a 10- to 15-year life expectancy.

Otherwise, the guideline recognizes that men younger than 55 years at higher-than-average risk for prostate cancer as well as some men over age 70 years who are in excellent health may benefit from prostate cancer screening. It states that decisions for men younger than 55 years of age should be individualized based on personal preferences and an informed discussion regarding the uncertainty of benefits and the harms of screening. For older men (>70 years of age) who choose screening through shared decision making, the panel suggested the harms of screening may be reduced by using a higher PSA threshold for prostate biopsy (>10.0 ng/mL) and by discontinuing screening in men with a lower PSA level (<3.0 ng/mL).

Dr. Carter also noted that the panel recognizes the need for periodic updating of the guideline considering existing knowledge gaps.

“Benefits from screening beyond a decade have yet to be assessed in a large randomized, controlled trial, and there is an absence of direct evidence for a screening benefit outside the target age range in non-Caucasians and men with a positive family history,” he said.

“In addition, the ideal approach to serial PSA testing is unknown, and there is an absence of direct evidence for a benefit of tests other than PSA for primary screening.”

The full guideline may be accessed at: http://www.auanet.org/common/pdf/education/clinical-guidance/Prostate-Cancer-Detection.pdf.UT