Early Detection of Prostate Cancer: AUA GUIDELINE

The PSA era started at the end of 1980's, even though it had been discovered as far back as the 70's. Although it is common knowledge that an elevated PSA is an indicator for prostate cancer, exactly how to use it in determining the next step in a patient's management has always been controversial.

In fact, in May 2012 the U.S. Preventive Services Task Force released a recommendation, "against PSA-based screening for prostate cancer."

"Prostate cancer is a serious health problem that affects thousands of men and their families. But before getting a PSA test, all men deserve to know what the science tells us about PSA screening: there is a very small potential benefit and significant potential harms. We encourage clinicians to consider this evidence and not screen their patients with a PSA test unless the individual being screened understands what is known about PSA screening and makes the personal decision that even a small possibility of benefit outweighs the known risk of harms."

The also conclude that, "many men are harmed as a result of prostate cancer screening and few, if any, benefit."  They rated this as a Grade D recommendation, which is indicates that, 

"The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits." And that they, "Discourage the use of this service." Such a sweeping recommendation by a prominent agency prompted the American Urological Association to respond within a month. Dr. John M. Lynch said,  © Fox Broadcasting Corporation "I think we would all agree that the appropriate use of PSA and DRE, combined with informed consent, especially in at-risk populations, does indeed reduce deaths from prostate cancer. It is a disservice to men to deny them the opportunity for potential treatment and cure, when necessary, for a disease that affects one in six over the course of their lifetime."  These reflect my own personal opinions on Prostate Cancer screening. These are think are the keywords for practical consideration.  PSA should be combined with DRE... a patient should be informed about the issues about screening... AND it is absolutely essential for patients who are at risk! This seems to have stimulated the AUA to produce a concrete set of guidelines for the Early Detection of Prostate Cancer which is now sort of an update to their previous 2009 Prostate-Specific Antigen Best Practice Statement. The guidelines are composed of five statements that summarize the panel's findings based on over a hundred high quality papers. ********* "Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years. (Recommendation; Evidence Strength Grade C) In this age group there is a low prevalence of clinically detectable prostate cancer, no evidence demonstrating benefit of screening and likely the same harms of screening as in other age groups." Even though the Evidence Strength is Grade C, I don't think there are any controversies here. "Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk. (Recommendation; Evidence Strength Grade C) For men younger than age 55 years at higher risk (e.g. positive family history or African American race), decisions regarding prostate cancer screening should be individualized." This probably is the greater change in the practice of Philippine Urologists.  In the past, PSA screening was a must for men 50+ of age, and 45+ for those of high risk.  A few years ago, it was lowered to 40+ years old, with some arguing that the normal value for PSA should also be lowered.  Now we've gone the other direction, increasing to 55 + years of age for patients without risk.  AND for Filipino patients who are said to have a lower risk for prostate cancer as compared to African Americans and Caucasians, even the more so this is significant. "Guideline Statement 3: For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man's values and preferences. (Standard; Evidence Strength Grade B)" The greatest benefit of screening appears to be in men ages 55 to 69 years." This is a prudent recommendation.  However, in practice, one doesn't want to be the Urologist who first saw a patient, elected NOT to screen, then a few years down the line same patient is discovered to have prostate cancer... and it turned out to be advanced. There will always be a question in the patient's mind that if Urologist A had screened him, could this have been organ-confined?!  Personally, I'd recommend screening, give the patient the advantages and risks and if he decides not to, I'd note it specifically in his record that he opted not to. "Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives. (Option; Evidence Strength Grade C) Additionally, intervals for rescreening can be individualized by a baseline PSA level." Again, another prudent recommendation.  Unfortunately, it still goes back to the individual Urologist on what baseline PSA level will prompt you to do it more often. Will you do an annual PSA for a patient with a baseline of 2.5 or 3.0 or 3.5?? "Guideline Statement 5: The Panel does not recommend routine PSA screening in men age 70+ years or any man with less than a 10 to 15 year life expectancy. (Recommendation; Evidence Strength Grade C) Some men age 70+ years who are in excellent health may benefit from prostate cancer screening." It's a good thing they included, "age 70+ years who are in excellent health...."  My classic argument to our residents when they mention an absolute age cut-off is, "What if the patient tells you that even though he is 75 years old, he wants to live up to 100... and who are you to say that my life is about to end?!"  Of course, I'll still screen these patients! Let me quote a statement by my good friend Dr. Jorge Yao, who's a Genito-Urinary Pathologist at the University of Rochester Medical Center in New York,  "The problem with Prostate cancer is not screening but determining which cancer needs to be treated aggressively." The conversation started with the topic of BRCA-related prostate cancer, and he continues by stating, "BRCA related prostate cancer is aggressive compared to non-BRCA prostate cancer and should be treated aggressively. This is the type of PCa that needs to be screened for and treated early. One of the best prognostic indicators for aggressive behavior in PCa is early onset and familial history."  Although these statements are excellent guides for us Urologists in recommending screening to our patients, I think Jorge hits the nail on the head exactly right.  New modalities should be developed in order to determine which cancers are truly aggressive.  The Gleason Score is a good tool, but remember, it was developed at the time where the specimens being graded and scored where either whole prostatic adenomas from open prostatectomies or prostatic chips from a transurethral resection (TURP). I think it's high time that a new method of assessing needle biopsy specimens and definitively identify which cancers will ultimately be aggressive.  Are all Gleason 6 truly low-risk for progression... or is there a better way?  I hope it comes soon!