AUA Revises Its Guidelines for PSA Screening

­San Diego, CA—Prostate cancer screening with prostate-specific antigen (PSA) tests should focus on men aged 55 to 69 years, the group that is the most likely to benefit from screening, according to a new clinical guideline issued by the American Urological Association (AUA) at its 2013 annual meeting. This represents a significant shift from the previous position held by the AUA for strong support of PSA screening for men of all age-groups.

The new AUA position now does not recommend routine PSA screening tests for average-risk men aged 40 to 54 years. The organization recommends against PSA screening for men aged <40 years. Screening for men aged ≥70 years “is not recommended,” nor is screening for men of any age who have a life expectancy of less than 10 to 15 years. The AUA acknowledges that some older men aged ≥70 years and in excellent health may benefit from screening and should be evaluated on an individual basis.

Regardless of age or recommendation, the AUA emphasizes that screening should proceed only after a careful discussion with the patient about potential benefits and risks of screening. The decision to screen should be a shared one between physician and patient. “It’s time to reflect on how we screen men for prostate cancer and take a more selective approach in order to maximize benefit and minimize harms,” said the guideline panel chair H. Ballentine Carter, MD, Professor of Urology at Johns Hopkins University in Baltimore. “Our focus was to help urologists identify those individuals who are most likely to benefit from being tested,” Dr Carter said. “The conclusion we came to, based on the evidence, was that the group more likely to benefit would be men ages 55 to 69, which is where we should be focusing our efforts.”

The recommendation pertaining to men aged 40 to 54 years is likely to be the most controversial aspect of the guideline, Dr Carter added in a video interview released by the AUA. Patients in that age range have a low risk of prostate cancer and a very long lead time with respect to testing. If they are tested and are found to have prostate cancer, the disease is likely to be in a very early stage, including what many urologists and oncologists have termed “clinically insignificant” or “inconsequential” cancers. If men in the 40- to 54-year-old age group are treated, they will “live with the harms of treatment for a very long time,” he emphasized. “For all of those reasons, we concluded that these men, while some may benefit [from screening], there is probably more harm than benefit as compared with beginning screening at age 55,” said Dr Carter.

The new guideline replaces an AUA Best Practice Statement that was issued in 2009. The practice statement supported screening of average-risk men in the 40- to 54-year-old age-group. However, the statement also addressed risk stratification and prostate cancer management. The guideline has a sole focus on the use of PSA screening tests. Moreover, the practice statement relied heavily on expert and consensus opinions. The guideline was derived from a review of published evidence through 2012. In addition to the age-related recommendations, the guideline offers physicians the option to screen less frequently than annually in appropriately selected men. The decision to screen every other year, or even less frequently, should be preceded by a careful discussion with the patient, and should be guided by the patient’s baseline PSA value.

The US Preventive Services Task Force recommendation against routine screening for men of any age was targeted to primary care physicians, and was strongly objected to by urologists. By contrast, the AUA guideline emphasizes that the recommendations apply to urologists.

The AUA “is not dismissing the PSA test as the task force has done,” said guideline committee member Philip W. Kantoff, MD, Director, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, and Professor of Medicine, Harvard Medical School, Boston. “There should be a more reasonable approach to the use of PSA.”

In keeping with AUA policy, the guidelines will be updated as appropriate in response to new information about prostate cancer screening, said Dr Carter.

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