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.

NEW AUA Guidelines for Castration-Resistant Prostate Cancer

During the 2013 Annual Meeting of the American Urological Association, new guidelines for the treatment of Castration-Resistant Prostate Cancer (CRPC).  CRPC has always been a vexing problem to Urologists since Hormone Therapy was developed by Charles Huggins in 1941.  Although quite effective initially, especially for advanced prostate cancer, it had been found that castration or hormone ablation gradually became less effective after several years, and thus the identification of "Hormone-Resistant Prostate Cancer (HRPC)" made.

In recent years, it has been found that HRPC was found to still be quite sensitive to other forms of hormone therapy, in particular, those that interrupt the steroid synthesis pathway at a "higher" level compared to medical or surgical castration.  This also explains why second-line hormone therapies such as estrogens and ketoconazole was found to be somewhat effective. Thus, the term "Castration-Resistant Prostate Cancer" came into being.

With the development of novel new therapies that are still hormonal in nature, the AUA has now released treatment guidelines that focus on six (typical) "index" patients.  These include:

1. Index Patient 1: Asymptomatic, non-metastatic CRPC
2. Index Patient 2: Asymptomatic or minimally symptomatic, mCRPC without prior docetaxel chemotherapy
3. Index Patient 3: Symptomatic, mCRPC with good performance status and no prior chemotherapy
4. Index Patient 4: Symptomatic, mCRPC with poor performance status and no prior docetaxel chemotherapy
5. Patient 5: Symptomatic, mCRPC with good performance status and prior doxetaxel chemotherapy
6. Index Patient 6: Symptomatic, mCRPC with poor performance status and prior docetaxel chemotherapy

Many clinicians have recognized the importance of releasing such guidelines as in the past, there was lack of cohesion in what exactly would be the best course for these groups of patients.  Most of the time, clinicians would have to wade through tons of research material or attend special symposiums to get some degree of clarity... only to be debunked a few months later.

"Prior to 2004, once patients failed primary androgen deprivation, treatments were administered solely for palliation,"

To read the full text fo the guidelines, visit the website of the American Urological Association or click here.