screening

Detection of Prostate Cancer: AUA Guideline

NONE

Disclosures

Peter Albertsen

Michael Barry

Ruth Etzioni

Stephen Freedland

Kirsten Greene

Lars HolmbergPhilip KantoffBadrinath KonetyDavid PensonAnthony Zeitman

Panel Participants

AUA Staff:Heddy Hubbard Michael FolmerErin Kirby Abid KhanPatricia Lapera

BEST PRACTICE STATEMENTEvaluation of PSA for detection, risk stratification, management of prostate cancer

Not systematic literature review

Recommendations based on clinical experience and expert opinion

Current Guideline Differs from PSA Best Practice Statement

(2009)

Evidence based evaluation of prostate cancer detection to reduce prostate cancer mortality

Statements based on evidence rather than values, opinion, or clinical experience

Findings intended to assist the urologist in advising an “average” risk man without symptoms about prostate cancer screening

Guideline Purpose

Systematic review of published studies relevant to diagnosis/screening of prostate cancer from Jan 1995 to Feb 2013 Digital rectal examination Serum and urine biomarkers alone/combination Imaging Genetics Prostate biopsy Shared decision making

Methodology: Literature Review

With the exception of PSA-based screening, there was minimal evidence to assess pre defined outcomes of interest using other tests –

324 eligible studies addressed:•Prostate cancer incidence and mortality•Quality of life•Diagnostic accuracy•Harms of testing

Methodology: Systematic Review

Framework: PSA Focused Guideline

Rating of Evidence Strength and Quality

• Standard (evidence level A/B)

Benefits are >or< than the harms

• Recommendation (evidence level C)

Benefits are >or< than the harms

• Option (evidence level A-C)

Benefits = harms or balance is unclear

Linking of Evidence to Statement Type

The panel did not go beyond the evidence in formulating STATEMENTS

•Quality of the evidence • Benefits of screening – moderate (B)

• Harms of screening – high (A)

Interpretation of Evidence

The panel evaluated the early detection of prostate cancer in average risk men by age, recognizing that the harm-benefit ratio is highly age-dependent

• < 40yrs• 40-54yrs• 55-69yrs• 70+yrs

Guideline Statement Organization

Recommend against PSA-based screening of men under age 40yrs (Recommendation; Evidence Strength: Grade C)

In this age group there is a low prevalence of clinically detectable prostate cancer, no evidence demonstrating a benefit for screening, and likely the same harms of screening as in other age groups

Guideline Statement 1: Age <40yrs

Screening as a routine is not recommended in men between ages 40-54yrs at average risk (Recommendation; Evidence Strength: Grade C)

The evidence for benefit is marginal when compared to screening beginning at age 55yrs, and the quality

of evidence for harm is high

Guideline Statement 2: Age 40-54yrs

Men age 40-54yrs are often screened presuming that they have the most to gain from treatment because of an increased life expectancy

Low prevalence of fatal prostate cancer, long lead times, and extended time at risk for harm from treatment, all may lead to greater harm than benefit

Guideline Statement: Age 40-54yrs

For men younger than age 55yrs at higher than average risk, decisions regarding prostate cancer screening should be individualized based on personal preferences, and an informed discussion regarding the uncertainty of benefit and the harms of screening should take place prior to a decision

Guideline Statement: Age 40-54yrs

The panel recommends shared decision making for men age 55-69yrs considering PSA testing, and proceeding based on a patient’s values and preferences (Standard; Evidence Grade: B)

A decision to undergo screening must weigh the benefit of preventing 1 prostate cancer death per 1000 screened over a decade vs the harms of screening and treatment

Guideline Statement 3: Age 55-69yrs

Shared decision making should include a discussion of a man’s life expectancy and prostate cancer risk based on race and family history, and the degree to which screening might influence this risk

PSA-based screening should not be performed in the absence of shared-decision making (e.g., health fairs, health system promotions, community organizations)

Guideline Statement: Age 55-69yrs

A routine screening interval of 2yrs or more may be preferred over annual screening in those men who have participated in shared-decision making and chosen screening. As compared to annual screening, it is expected that screening intervals of 2yrs preserve the majority of benefits and reduce over diagnosis and false positives (Option; Evidence Grade: C)

Intervals for rescreening can be individualized by a baseline PSA level and/or prior PSA history

Guideline Statement 4: Reducing Harms of Screening

Recommend against routine PSA-based screening in men age 70+ yrs, or in any patient with less than a 10-15yr life expectancy (Recommendation; Evidence Grade: C)

Some men over age 70yrs who are in excellent health may benefit from prostate cancer screening

An absolute reduction in mortality while possible is likely small, and the potential for harm high, or at least higher than benefit

Guideline Statement 5: Age 70yrs and Above

For the older man who has chosen screening, the panel suggests the following to reduce harm

• the use of higher PSA thresholds for prostate biopsy (e.g., 10ng/ml)

• discontinuation of screening in men with lower PSA levels (e.g. <3ng/ml)

Guideline Statement: Age 70yrs and Above

• Benefits from screening beyond a decade have yet to be assessed in large RCT’s

• Absence of direct evidence for screening benefit outside the age range 55-69yrs, non-Caucasians, positive family history

• Ideal approach to serial PSA testing is unknown

• Absence of direct evidence for a benefit of tests other than PSA for primary screening

Guideline Requires Periodic Updating

The panel’s goal is to present an evidence based approach to prostate cancer detection that targets men most likely to benefit, and improves the ratio of benefit/harm

For more information, please attend:Detection of Prostate Cancer and Castration

Resistant Prostate Cancer CourseMay 6, Noon-1:30PM, San Diego CV 6C

Summary: AUA Guideline on Early Detection of Prostate Cancer