At a time of controversy regarding the value of PSA screening in the early detection of prostate cancer, the 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.
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.
The review of evidence resulted in a detailed discussion of the potential risks of PSA testing, but also the limitations of the data and their sources. Consistent with the emphasis on shared decision making, the guideline includes a section called “What a Man Needs to Know Prior to Making a Decision About Testing.”
The AUA has distanced itself from routine screening in any age group, including the 55 to 69 group. Instead, the guideline recommends individualized decision making, noting that screening intervals of 2 years or longer might be appropriate for some 55- to 69-year-old men.
“The main point is that PSA testing for early detection of prostate cancer has an important role in maintaining the health of American men,” Wolf said. “Clearly, it has been overused in the past, but we feel it is a grave mistake to react to that overuse by completely getting rid of any early-detection efforts at all. We feel that a more balanced approach—selecting men at higher risk—is a more appropriate way to go.”
As an aid to shared decision making about prostate cancer screening, the AUA has developed an education program with information for providers and patients. As part of that effort, the AUA is offering a free toolkit to doctors and patients that includes a frequently asked questions document; a flow chart that explains who is a good candidate for PSA screening (Figure); a brochure; a fact sheet; a checklist; and a patient booklet (http://tinyurl.com/mn56qmx). “Because the AUA’s primary audience is urologists, the educational materials have been developed for urologists to distribute to patients during office visits,” Wolf said. “The materials are designed to facilitate discussion between providers and patients, because we recognize the discussion is not an easy one for providers who are unfamiliar with the issues and considerations that go into making a decision about PSA testing.”
Clinicians and patients can access the entire guideline on the AUA website (www.auanet.org), which also has a link to the Urology Care Foundation, an AUAsponsored initiative developed specifically for patient education. Additional patient-oriented material is available at KnowYourStats. org, a website that builds on the organization’s longstanding prostate cancer awareness campaign developed in conjunction with the National Football League.
“To achieve the goal of a balanced approach to use of PSA testing for early detection of prostate cancer, the patient and physician bear a pretty high burden for education,” Wolf said. “That is the basis for the public education program. Urologists need to know a lot and patients need to know a lot.”
Clinicians and patients also should recognize that the clinical guideline is just that—a guideline.
“This is not a mandate or a requirement. It’s a guideline,” Freedland said. “Patients who are outside the guidelines, and understand the risks and benefits of testing, may say ‘I want to be tested.’ From the perspective of a practicing urologist, I am not going to use a guideline to say ‘No, you cannot do this’ or ‘Yes, you must do this.’ The guideline provides a starting point for the discussion between physician and patient.”
This wall chart is part of the toolkit being offered by the AUA to spread the word about its guideline on PSA screening