SAN DIEGO, CA USA (UroToday.com) - In a plenary session that was so well attended the room was over seating capacity, Dr. Ballentine Carter (Johns Hopkins) presented the new AUA 2013 Clinical Practice Guideline on the early detection of prostate cancer (PCa), which is an update on the 2009 best practice statement.
AUA clinical practice guidelines are developed through a rigorous, systematic review of published literature, whereas the original best practice statement was based largely on expert consensus. The new guidelines present an evidence-based evaluation of the effect of early PCa detection on decreasing PCa mortality. The guidelines are intended to assist the urologist in advising patients who are at an average risk for the development of PCa on the risks and benefits of PSA screening.
All relevant studies from 1995 to February of 2013 were included (a total of 324 studies were addressed). Studies reviewed included randomized, controlled trial data, modeled, and population data. All data were interpreted from an individual as opposed to a public health perspective. As standard for the AUA guidelines, the quality of evidence was rated as A, B, or C, and all statements were classified as standards (benefits outweigh harms), recommendations (benefits > or < harms), or options (benefits = harms or balance is unclear). Overall, the quality of evidence for screening was moderate. The quality of evidence for screening was moderate. The statements were categorized by age, and apply to average risk men. For men < 40 years old, the AUA recommends against routine PSA based PCa screening (Level C ). For men aged 40-54 years, routine screening is not recommended for average-risk men. To date, there have been no randomized, controlled trials including men < 55yrs of age. The probability of dying from PCa by age 55 is 0.02% (SEER data), and 0.004 deaths will be prevented per 1 000 patients screened if started at < 55 years old. Lead times in younger men are longer, and they are, for a greater time period, at risk for harm if treated. For high-risk men < 55 years old, decisions to screen should be individualized after informed discussion.
For men 55-69 years old, shared decision-making should be employed (standard; grade B). Trials of screening in breast, lung, and prostate cancer were compared. Screening breast cancer patients results in a 20% relative reduction in cancer-specific mortality (CSM), with an absolute reduction of 4/1000 needed to treat to prevent one death. For lung cancer, screening results in a similar 20% reduction in CSM, and an absolute reduction of 4/1000. Based on data from the European Randomized Trial of Screening in Prostate Cancer (ERSPC), PSA screening reduces cancer specific mortality by 21% (OR 0.79), with an absolute risk reduction of 1/1000. Life expectancy and PCa risk should be discussed with patients prior to screening, and PSA screening should not be routinely offered at health fairs or community events.
A routine interval of PSA screening of 2 years or more may be preferred over annual screening (option; grade C). For men > 70 years old or in any patient with less than a 10-15 year life expectancy, the guidelines recommend against PSA screening (recommendation; grade C). Based on data from ERSPC, there is no evidence for a screening benefit or a treatment benefit after diagnosis (Bill-Axelson, NEJM, 2011). Over-diagnosis increases with age and patients are at risk of dying from other causes. If older patients still choose screening after an informed discussion, the threshold for biopsy should be higher (PSA > 10ng/mL). Discontinuation of screening in men with lower PSA levels (< 10ng/mL) should be considered. Benefits from screening beyond a decade have yet to be assessed in a large, randomized controlled trial, and the ideal approach to serial PSA testing is unknown.
Dr. Carter emphasized that the guidelines are not equivalent to discarding the PSA test, but rather describe a smarter use of screening and an attempt to improve the ratio of benefit to harm associated with PSA testing.
Dr. William Catalona (Northwestern University) then posed an interesting question when he asked why a draft of the guidelines was not circulated to the urology community, for comment, prior to public dissemination of the guidelines, which would be in accordance with the guideline protocols established by the institute of medicine. The panel indicated that they specifically opted for no period of public discussion because of the extensive peer-review process that was performed. The panel is now entertaining the idea of allowing a period of public comment by the urologic community.
Presented by H. Ballentine Carter, MD at the American Urological Association (AUA) Annual Meeting - May 4 - 8, 2013 - San Diego Convention Center - San Diego, California USA
Professor of Urology, Oncology at Johns Hopkins Medicine and Director, Division of Adult Urology the Brady Urological Institute in Baltimore, MD
Reported for UroToday.com by Jeffrey J. Tomaszewski, MD
Click HERE to download the complete guideline
Click HERE to view the slide presentation from this session