Further comment from the AUA on new PSA screening guidance

The American Urological Association (AUA) sent the following additional message to its members with the past 90 minutes:

Dear AUA Member,

On Friday, May 3, the AUA released a new clinical guideline on the Early Detection of Prostate Cancer. The new guideline has been in development for nearly two years and was peer reviewed by more than 50 AUA members prior to being approved by the AUA’s Board of Directors. While much of the media coverage concerning the guidelines has been accurate, some outlets have mistakenly stated that the AUA has changed its position and is now recommending against prostate cancer screening in all men at risk for this common disease. In fact, this is not at all what the guidelines state. Compared to our 2009 best practice policy document, the guidelines do narrow the age range in which informed decision making around PSA screening should be offered to men at average risk for prostate cancer, but they do not make a blanket statement against screening, as some have implied. Importantly, the guidelines only apply to men at average risk. The guidelines do not apply to symptomatic men or those at high risk for disease (men with a family history or of African-American race), who are encouraged to discuss their individual case with their doctor, regardless of their age.

Acknowledging this, there are some changes that have been made to the guidelines in response to recent new studies on screening. Specifically, in men age 40-54 at average risk for the disease, the guidelines recommend that screening, as a routine practice, should not be encouraged. Simply put, the evidence for the benefit for screening in this age range was limited while the quality and strength of the evidence regarding the harms of screening was high. This does not mean that we are recommending AGAINST screening; it simply means that there is insufficient evidence to support routine screening in this population at this time.

The other key change is in men over age 70 or those with less than a 10-year life expectancy in whom routine screening is not recommended. However, the guidelines acknowledge that some men over age 70 in excellent health may benefit from screening. In this setting, the guidelines suggest that a discussion of the unique risks and benefits of screening in older men occur.

The highest quality evidence for benefit (defined as lower prostate cancer mortality) of screening was found in men ages 55 to 69, and this evidence demonstrated that one man per 1,000 screened at 2- to 4-year intervals will avert a prostate cancer death over a decade. However, over a lifetime, this benefit could be much greater.

In men age 55-69, the guidelines still strongly recommend shared decision-making and screening based on a man’s values and preferences. The only difference here is that the guidelines now recommend biennial screening to reduce the potential harms of screening.

Additionally, it should be noted that the AUA remains in disagreement with the U.S. Preventive Services Task Force in recommendation against prostate cancer screening in all men, regardless of age or risk, without even considering a discussion of the risks and benefits of screening. The AUA continues to support a man’s right to be tested for prostate cancer — and to have his insurance pay for it, if medically necessary.

The AUA is in the process of preparing supplemental materials that urologists can share with primary care providers in their communities, and will be working with major patient advocacy groups to ensure that patient education materials are available. More information about these tools will be available in late May; the toolkit will be available on AUAnet.org.

8 Responses

  1. I”d like to know the AUA defintion of: “Man’s values and preferences” as well as “potential harms of screening.”

  2. I believe that the U.S. Preventive Services Task Force recommendation against PSA screening is incredulous and beyond belief. A simple blood test for PSA? Hello? Or maybe it is a plan going forward to save Social Security and Medicare? Think of it, have men die earlier of prostate cancer and they have less Medicare cost and Social Security to pay out! They will probably advise women not to screen for breast cancer next!

  3. Dear Jim:

    The USPSTF has already recommended that mammography is not a scientifically effective screening method for the majority of women. And actually they are correct. It isn’t.

  4. Definitely not GFMPH! (Good For Men’s Prostate Health)


    I am reassured by the second of these two sentences that the AUA is aware of the tentativeness of current ERSPC results and the likelihood of a much greater apparent benefit in the future: “The highest quality evidence for benefit (defined as lower prostate cancer mortality) of screening was found in men ages 55 to 69, and this evidence demonstrated that one man per 1,000 screened at 2- to 4-year intervals will avert a prostate cancer death over a decade. However, over a lifetime, this benefit could be much greater.”

    Indeed, we already have a strong indicator of such likelihood of a much greater benefit. We should be keenly aware of the change in the ERSPC projection of benefit with just two more years of follow-up. The initial report of ERSPC results in the NEJM in March 2009 stated, based on a median follow-up of 9 years, that 1,410 men would need to be screened to prevent one death from prostate cancer. In sharp contrast, just two more years of median follow-up, published in the March 15, 2012 issue of the NEJM, projected that 1,000 men would need to be randomized to screening to prevent one death. However, this sharp decline of more than 400 men needing to be screened to prevent a death is not being reported; rather, only the static snapshot of 1,000 men to prevent a death is being reported.

    Moreover, the latter statistic is based on the numbers of men assigned to the two groups in the study, not to the men who actually underwent screening versus those who did not. The 11-year update commented on this, noting that, in the core age group, the “relative reduction in the risk of death from prostate cancer in the screening group was 21% … [statistical details], and 29% after adjustment for non-compliance.” Let me add an exclamation point! In other words, when mortality for those actually screened was compared to mortality for those actually not screened, the reduction in mortality was 29%, a percentage 38% higher than the somewhat artificial survival rate of 21% based solely on randomization to screening rather than actual screening. I hope the AUA will find a way in the future to indicate these clues to a potentially much greater benefit for screening.

    I remain concerned that this follow-up statement refers to “over a decade” of follow-up, without making the critical point that follow-up since diagnosis had to be substantially less than a decade. That point is so important, especially to the community in the US, as 10-year survival in the US is near 100% except for cases that are extremely high in risk. In other words, even at 11 years of follow-up in the ERSPC group since randomization, I suspect we are observing mortality mainly among men with extremely high-risk cases. It seems likely the real impact of screening in this trial will not be evident for many more years.

  6. Welcome to the world of “evidence based” medicine. Now if I could only figure out whose evidence, and whose interpretation of that evidence to believe. (The most unbiased appears to bethat of the USPSTF.)


    John, I’m replying to your comment of 5/7/2013 of 9:41 pm.

    The USPSTF may be the most unbiased, but they are arguably by far the most ignorant of medical groups weighing in on screening, with no voting member in a field of medicine involved in treatment of prostate cancer! This was not a panel of experts in prostate cancer, though the members had expertise in other fields of medicine!

    The USPSTF failed to understand the role of active surveillance (AS) in separating serious prostate cancer from disease that does not need to be treated. They give AS lip service, at best.

    The USPSTF failed to understand the numerous very serious shortcomings of the PLCO and ERSPC trials as evidence for the value of screening. They ignored much evidence of the benefit of wisely done screening.

    The USPSTF failed to respond adequately and adjust their recommendation in the face of many public comments to them that should have been enough to explain their serious errors.

    In short, as far as prostate cancer screening is concerned, the USPSTF failed! Their recommendation deserves neither credence nor attention!

  8. John (and Jim):

    There is an alternative view, which is that the USPSTF’s recommendation is entirely understandable when looked at from the view of an epidemiologist or a primary care physician. It may not be “the best” recommendation — but that doesn’t invalidate the perspective that USPSTF brought to the discussion.

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