AUA 2023: AUA Guidelines: Early Detection of Prostate Cancer

(UroToday.com) The 2023 American Urological Association (AUA) annual meeting held in Chicago, IL between April 28 and May 1st, 2023, was host to a plenary session, with Dr. John Wei presenting the latest iteration of the joint AUA/SUO guidelines for the early detection of prostate cancer.

Dr. Wei began by highlighting that prostate cancer is the most commonly diagnosed visceral malignancy in American men. In 2023, it is estimated that almost 300,000 men will be diagnosed with and almost 35,000 will die from prostate cancer in the United States. With the increased utilization of multiparametric MRI (mpMRI) and biomarkers in clinical practice, Dr. Wei emphasized that it was time for an updated version of these guidelines for the early detection of prostate cancer.

Dr. Wei next presented the current guideline statements as follows:

PSA Screening

Clinicians should engage in shared decision-making with people for whom prostate cancer screening would be appropriate and proceed based on a person’s values and preferences, as opposed to routine, reflex testing.
When screening for prostate cancer, clinicians should use PSA as the first screening test.
For people with a newly elevated PSA, clinicians should repeat the PSA prior to a secondary biomarker, imaging, or biopsy.
Clinicians may begin prostate cancer screening and offer a baseline PSA test to people between ages 45 to 50 years.
Clinicians should offer prostate cancer screening beginning at age 40 to 45 years for people at increased risk of developing prostate cancer based on the following factors: Black ancestry, germline mutations, and strong family history of prostate cancer.
Clinicians should offer regular prostate cancer screening every 2 to 4 years to people aged 50 to 69 years.
Clinicians may personalize the re-screening interval, or decide to discontinue screening, based on patient preference, age, PSA, prostate cancer risk, life expectancy, and general health following shared decision-making.
Clinicians may use DRE alongside PSA to establish the risk of clinically significant prostate cancer.
For people undergoing prostate cancer screening, clinicians should not use PSA velocity as the sole indication for a secondary biomarker, imaging, or biopsy.
Clinicians and patients may use validated risk calculators to inform the shared decision-making process regarding prostate biopsy.

When the risk of clinically significant prostate cancer is sufficiently low based on available clinical, laboratory, and imaging data, clinicians and patients may forgo near-term prostate biopsy.

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Initial Biopsy

Clinicians should inform patients undergoing a prostate biopsy that there is a risk of identifying a cancer, with a sufficiently low risk of mortality, that could safely be monitored with AS rather than treated.
Clinicians may use MRI before initial biopsy to increase the detection of GG2+ prostate cancer.
Radiologists should utilize PI-RADS in the reporting of mpMRI imaging.

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For biopsy-naïve patients who have a suspicious lesion on MRI, clinicians should perform targeted biopsies of the suspicious lesion and may also perform a systematic template biopsy
For patients with both an absence of suspicious findings on MRI and an elevated risk for GG2+ prostate cancer, clinicians should proceed with a systematic biopsy.
Clinicians may use adjunctive urine or serum markers when further risk stratification would influence the decision regarding whether to proceed with a biopsy.
For patients with a PSA > 50 ng/mL and no clinical concerns for infection or other cause for increased PSA (e.g., recent prostate instrumentation), clinicians may omit a prostate biopsy in cases where biopsy poses significant risk or where the need for prostate cancer treatment is urgent (e.g., impending spinal cord compression).

Repeat Biopsy

Clinicians should communicate with patients following biopsy to review biopsy results, reassess the risk of undetected or future development of GG2+ disease, and mutually decide whether to discontinue screening, continue screening, or perform adjunctive testing for an early reassessment of risk.
Clinicians should not discontinue prostate cancer screening based solely on a negative prostate biopsy.
After a negative biopsy, clinicians should not solely use a PSA threshold to decide whether to repeat the biopsy. (
If the clinician and patient decide to continue screening after a negative biopsy, clinicians should re-evaluate the patient within the normal screening interval (two to four years) or sooner, depending on the risk of clinically significant prostate cancer and life expectancy.
At the time of re-evaluation after a negative biopsy, clinicians should use a risk assessment tool that incorporates the protective effect of a prior negative biopsy.
After a negative initial biopsy in patients with a low probability for harboring GG2+ prostate cancer, clinicians should not reflexively perform biomarker testing.
After a negative biopsy, clinicians may use blood, urine, or tissue-based biomarkers selectively for further risk stratification if results are likely to influence the decision regarding repeat biopsy or otherwise substantively change the patient’s management.
In patients with focal (one core) HGPIN on biopsy, clinicians should not perform immediate repeat biopsy.
In patients with multifocal high-grade prostatic intraepithelial neoplasia (HGPIN), clinicians may proceed with additional risk evaluation, guided by PSA/DRE and mpMRI findings.
In patients with atypical small acinar proliferation (ASAP, clinicians should perform additional testing.
In patients with atypical intraductal proliferation, clinicians should perform additional testing.
In patients undergoing repeat biopsy with no prior prostate MRI, clinicians should obtain a prostate MRI prior to the biopsy.
In patients with indications for a repeat biopsy who do not have a suspicious lesion on MRI, clinicians may proceed with a systematic biopsy.
In patients undergoing repeat biopsy and who have a suspicious lesion on MRI, clinicians should perform targeted biopsies of the suspicious lesion and may also perform a systematic template biopsy.

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Biopsy Technique

Clinicians may use software registration of MRI and ultrasound images during fusion biopsy, when available
Clinicians should obtain at least two needle biopsy cores per target in patients with a suspicious prostate lesion(s) on MRI.
Clinicians may use either a transrectal or transperineal biopsy route when performing a biopsy.

Dr. Wei concluded his presentation of the updated prostate cancer early detection guidelines by highlighting future topics of required research:

Future screening and diagnosis trials that include historically underrepresented populations
Development of validated decision aids that facilitate the shared decision-making process for prostate cancer screening
Further evaluation of the impact of race and ethnicity on the operating characteristics of PSA, secondary biomarkers, and prostate imaging
Research into prostate cancer screening preferences, the accuracy of biomarkers, potential psychological consequences, and impact of gender-affirming hormonal therapy in non-binary patients and transgender women.
Further comparative outcomes research of the benefit of various serum, urine, tissue, and imaging biomarkers to assess the likelihood of high-grade prostate cancer
Further evaluation of transperineal versus transrectal biopsies
Methods to improve the detection/targeting of MRI-positive lesions and further evaluation of evolving MRI protocols, such as biparametric MRI and use of artificial intelligence in this setting.

Presented by: John Thomas Wei, MD, Professor, Department of Urology, University of Michigan, Ann Arbor, MI

Written by: Rashid K. Sayyid, MD, MSc – Society of Urologic Oncology (SUO) Clinical Fellow at The University of Toronto, @rksayyid on Twitter during the 2023 American Urological Association (AUA) annual meeting held in Chicago, IL between April 28 and May 1^st, 2023

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