AUA report and update no. 4: Monday, April 27, 2009

The American Urological Association (AUA) has issued new guidance on the use of PSA testing in the early detection of prostate cancer.

“Many men do not need yearly screening,” but each man’s risk should be individually assessed, said Dr. Peter Carroll, who led the panel that has just rewritten the AUA guidelines. They are being issued this morning. We have not yet seen the actual guidance document.

The AUA’s new guidance says that men should be offered a baseline PSA test at age 40, and follow-ups at intervals based on each man’s situation. A high PSA at age 40 greatly predicts a risk of prostate cancer, said Carroll. This guidance brings the AUA closer to agreement with other guidelines since it clearly implies the importance of discussion between a patient and his doctor.

Doing a baseline test “makes a lot of sense to me,” said Dr. Eric Klein, prostate cancer chief at the Cleveland Clinic.

There is already controversy over these revised guidelines — which was only to be expected. A scientist at the National Institutes of Health, Dr. Barnett Kramer, is already being quoted as saying that, “There is no proof that a baseline test will save lives” and that “The same issue of harm comes up — overdiagnosis. A baseline PSA, just like regular PSA screening, can lead to the diagnosis of cancers that would not have harmed a man had they not been detected.”

We should note that new studies at the AUA annual meeting do seem to suggest predictive benefits to testing.

Dr. Hans Lilja of Memorial Sloan-Kettering Cancer Center in New York tested stored blood samples from nearly 1,200 Swedish men from the early 1980s and checked cancer registries to see how many later developed or died of prostate cancer.

If the men’s PSA level was 1 or less at age 60, the risk of dying of prostate cancer by age 85 was very low — less than 1 percent — even if men had the disease for many years. About 90 percent of cancer deaths occurred in men whose PSAs at age 60 were in the top 25 percent of the group.

In a different study, Dr. E. David Crawford of the University of Colorado Health Sciences Center studied 29,000 men from the PLCO screening study reported last month. Only about 1 percent of those whose initial PSA level was < 1 ng/ml saw their scores rise above 4 ng/ml in the next 5 years. Those with higher baseline scores had a much greater chance of that happening.

Dr. Otis Brawley, the American Cancer Society’s chief medical officer, believes there is still some value to PSA testing, but added: “I am very concerned that the urology community and the American public may think there’s more value in PSA than there actually is.”

One Response

  1. Good to see the rewrite! The truth is coming out: there is no clear path at any point — screening to treatment — for prostate cancer.

    It’s not just PSA screening — nothing is reliable: conventional 12-needle biopsy and treatment options as well.

    Men deserve to be told BEFORE they are given a PSA test — if they should so choose. Unless we are given the opportunity to make informed choices, we are no better than lab rats led into the maze by very selective information.

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