Updates in the Management of CRPC - Episode 1

Introduction: The AUA PSA Screening Guidelines

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Moderator, Raoul S. Concepcion, MD, introduces a panel discussion focused on guidelines and the many new treatments recently approved for castration-resistant prostate cancer. The goal of the discussion is to provide urologists with a range of expert perspectives on current challenges that affect both patients and practices. The conversation includes input from David Albala, MD, E. David Crawford, MD, Vahan Kassabian MD, Steven E. Finkelstein, MD, Stephen J. Freedland, MD, and David I. Quinn, MD.

The exchange begins with a discussion of the recent American Urological Association (AUA) guidelines on PSA testing. The guidelines have traditionally recommended that men age 40, if they’re African American or have a family history of prostate cancer, should be screened with a digital rectal examination and a PSA test, says Albala. In the update, the AUA now recommends screening for men age 55 to 69 who do not have risk factors for prostate cancer.

For the updates, the AUA looked toward data showing an improvement in survival as a result of screening, notes Freedland, who served as a member of the guideline decision panel. In the European Randomized Study of Screening for Prostate Cancer the core group of men studied were 59 to 69 years old with PSA testing done every four years. In this study, there was a clear connection between screening and a reduction in prostate-specific deaths, notes Freedland. However, the data for men age 40 to 54 was less clear. As a result, recommendations were not made for screening men in this age range.

These guidelines sparked controversy, since they followed a decision from the USPSTF to give PSA testing a D recommendation, Concepcion states. This decision was largely based on a fear that men diagnosed by PSA screening were being overtreated.

There is a clear need to separate diagnosis from treatment, Freedland says. However, when you examine actual practice patterns, at this time diagnosis and treatment are synonymous, with approximately 90% of patients with low-risk disease receiving treatment. As a result of this reality, current guidelines were based on current practice patterns, Freedland suggests.

The ability to separate diagnosis and treatment is rooted in the conversation between a physician and each patient, Albala believes. It is important, just like with every blood test, that the patient understands the implication of the results.