J. Stuart Wolf, Jr, MD
Professor of Urology
University of Michigan Health System
Ann Arbor, MI
At a time of controversy regarding the value of prostate-specific antigen (PSA) screening in the early detection of prostate cancer, the American Urological Association (AUA) has issued a new clinical guideline on the subject and launched an educational campaign designed to share the information with urologists and their patients.
As compared with previous AUA recommendations, the guideline more narrowly defines the profile of the asymptomatic patient who should receive PSA testing; at the same time, the guideline reaffirms the organization’s belief that the test has value, despite a government recommendation that its use be stopped altogether.
According to the Clinical Guideline on the Early Detection of Prostate Cancer, screening with PSA tests should focus on men aged 55-69 years, the age group most likely to benefit.
Routine screening is not recommended for average-risk men 40- 54, after age 70, or for men with an average life expectancy of less than 10 to 15 years. The AUA has recommended against screening PSA tests for men younger than 40.
Irrespective of patient age, a screening PSA test should not occur without a thorough discussion of the risks and benefits of screening between patient and physician, the guideline states.
The document emphasizes a more selective, evidence-based approach to PSA testing as compared with recent recommendations from other organizations, most notably the United States Preventive Services Task Force (USPSTF), said J. Stuart Wolf, MD, chair of the AUA Practice Guidelines Committee.
“The USPSTF essentially said that physicians should not offer screening PSA tests to any men,” Wolf said. “The AUA does not agree with that. We feel that PSA screening is a reasonable discussion to have between a physician and a patient. Our guideline emphasizes offering PSA tests to appropriately selected candidates.”
Even with appropriately selected patients, physicians should carefully discuss the potential risks and benefits of PSA testing and make a shared decision about proceeding with a test—or deciding against it.
“The average-risk man, 55 to 69, needs to be discussing the pros and cons of PSA testing,” said Stephen J. Freedland, MD, associate professor of Urology at Duke University in Durham, North Carolina, and a member of the writing committee for the PSA testing guideline. “Men at high risk—because of family history or African- American race—need to have this discussion earlier.”
Stephen J. Freedland, MD
Associate Professor of Urology
Moreover, the guideline does not preclude testing for men who are outside the high-risk age range, he added. A man who is age 70 or older, wants a PSA test, and has been appropriately educated about the process should not be excluded from testing.
“The key—regardless of a man’s age—is to discuss PSA testing with a physician and then make an informed decision,” Freedland said.
The guideline replaces a 2009 AUA best practices statement, which went beyond prostate cancer detection and included aspects of treatment and monitoring. In the practice statement, the AUA lowered the recommended age for a baseline PSA test to 40 and eliminated use of a specific PSA threshold for triggering a biopsy. The 2009 document had replaced earlier practice statements on the same topic.
Updating of the practice statement began about 2 years ago and was ongoing at the time the USPSTF announced its recommendation against routine PSA screening tests for asymptomatic men of any age.
“It was just time in the cycle for updating the best practices statement,” Wolf said, “so our practice guideline was not developed as a response to the USPSTF recommendations. Howewver, we did review the recommendations and used the clinical guideline to address what we considered to be some deficiencies in the USPSTF recommendations.”
The practice statement was based primarily on consensus and expert opinion. To develop the clinical guideline, the AUA commissioned an independent study of available evidence, as recommended by the Institute of Medicine. The review covered published literature from 1995 to 2013, a period that encompasses the introduction, evolution, and widespread use of PSA testing in clinical practice.