AUA issues new toolkit on prostate cancer screening


In a message sent out to its members this morning, the American Urological Association (AUA) has announced the availability of a new “toolkit” of materials designed to help doctors and patients in discussions about the pros and cons of testing individuals for their risk of prostate cancer. The key content of this message is given below:

In May 2013, the American Urological Association (AUA) released a new Clinical Practice Guideline on the Early Detection of Prostate Cancer. We understand that patients may be curious as to how the guideline may affect their decision to be screened for prostate cancer and that you may be receiving questions in your practice. As part of our ongoing communications with the medical community about the guideline, the AUA has prepared a toolkit of materials to assist you in discussing prostate cancer screening with your patients. This toolkit, which includes online resources, downloadable education documents and more, is now available online.

The toolkit includes the following materials:

  • Frequently Asked Questions about the 2013 AUA Guideline on Early Detection of Prostate Cancer
  • “Is Prostate Cancer Screening Right for You?” Wall Chart
  • “Is Prostate Cancer Screening Right for You?” Brochure
  • “What Men Should Know about Prostate Screening” Fact Sheet
  • “Is PSA Screening Right for Me?” Decision Tool/Checklist
  • “To Test or Not to Test for Prostate Cancer: A Shared Decision” Patient Fact Booklet
  • Patient Video

Also available in the toolkit are links to 2013 Plenary Session presentations and an AUA TV interview with Panel Chair Dr. H. Ballentine Carter.

All AUA members will receive mailed copies of the wall chart and brochure, which we hope will be helpful in your practices. Additional copies of these two tools are available (at minimal or no cost) through the AUA’s website.

The “New” Prostate Cancer InfoLink has not had the chance to review all of this material as yet, and so we cannot comment on the content. (We literally received this information within the past 30 minutes.) However, it will clearly reflect the position laid out by the AUA in its guideline issued in May. Having said that, we felt that we should immediately inform our readers about the availability of the new materials so they had the opportunity to review the content themselves. This may be particularly important for patient support group leaders and other prostate cancer educators.

10 Responses

  1. I read most of the materials. The different forms convey the same message, there is consistency. Dr. Carter’s video does the same.

    I find the message lacks transparency and is biased as to the harms of treatment and the lack of treatment benefit. They make reference to the 1000:1 screen to benefit ratio as of 2011. They failed to mention clearly that 2 years prior the ratio was 1410:1 and the trend with more follow-up will have a high probability to continue to be favorable to screening. They do report how screening leads to over-diagnosis and over-treatment with no benefit and much harm

    For men under 54 years of age, this educational material leaves them clueless. The material tries, but (in my humble opinion) falls short on the effort. This is consistent with all informed consent forms I have read. For every favorable statement for PSA testing there one unfavorable statement and then some. Nothing about the significant reduction in prostate cancer deaths as part of the information.

  2. Checking with my local urology group to see if I can get an extra copy/kit if they end up having one, since obviously as a mentor I want to be up-to-snuff on such recommendations.

  3. CAN’T ACCEPT THIS GUIDELINE AS WISE — VERY DISCOURAGING! … THE “10- TO 15-YEAR” YARDSTICK

    First, thanks Sitemaster, Ralph and Chuck for your work!

    Here’s what the brochure says about what I’ll call the “10- to 15-year yardstick” in their FAQ document:

    “Q: Does this mean that the AUA is moving more in line with the 2012 U.S. Preventive Services Task Force recommendations on PSA testing?

    “A: Our new guideline supports the use of the PSA test in a more targeted manner, whereas the USPSTF recommendations do not recommend its use in men of any age. We feel that men ages 55 to 69 who are in good health and have more than a 10- to 15-year life expectancy should have the choice to be tested and not discouraged from doing so.”

    Here is my concern. Back in the 70s, SEER information (seems like a sound set of data) showed that survival at 5 years was only about two of every three patients. We now have good evidence that US survival is virtually 100% at 5 years and 98% at 10 years (based on numbers from a few years ago, stated by the ACS on its site based on SEER data).

    Therefore, if we discourage screening unless a man has at least a 10-year expected lifespan, why are we not at risk of slipping back to only two of three surviving at 5 years and likely substantially fewer at 10 years? If you run numbers and find that your patient has a statistical likelihood of living only 8 more years, do you advise him not to be screened? Is there a way that makes sense? This could become more important as we get better life expectancy figures, which is now occurring.

  4. Dear Jim:

    Respectfully, back in the 70s when only 2 or 3 out of 5 patients were surviving for 5 years after a diagnosis of prostate cancer, the vast majority of those men were being diagnosed with evident metastatic disease. If we were to test men aged between 55 and 69 we would find most of those patients long before they became metastatic.

    However, I will continue to argue that most men still don’t need this sort of “screening” between the ages of 55 and 69 because the vast majority will still be at very low risk anyway. We need at better test that is specific for prostate cancer.

  5. “BEST AVAILABLE EVIDENCE” MAKES ME WORRY

    I strongly suspect the AUA considered the PLCO trial, the ERSPC trial, or probably both as constituting the “best available evidence.” That suspicion is based on seeing those trials treated with similar respectful descriptions in numerous published studies and media reports.

    I’m worried because those of us who have attended to Sitemaster’s articles and subsequent commentary know that both trials were flawed to the point that they really should be thrown out of court, rather than accepted as evidence. Ralph raised just one of many key points in his first post.

    Here’s where the FAQ for the guideline mentions the evidence:

    “Q Is the AUA worried that these new guidelines could result in an increased incidence of men over 55 presenting with advanced disease? Are you turning back the clock?

    A: Based on the best available evidence, there is no evidence that this will be the case. In fact, the evidence suggests that this guideline will lead to an improved benefit-to-harm ratio.”

    The AUA used the benefit-to-harm ratio earlier (Ralph’s point), so I’m suspecting strongly the AUA has no sound evidence to support its assertion. Is there other evidence that could be their “best available evidence”?

    Does anyone know whether the AUA or AUAF will be hosting one of its summits anytime soon? Maybe some of us could drive this vital point home.

    From a higher perspective, the Institute of Medicine seems to play the key role in defining “evidence”, and organizations like the U.S. Preventive Services Task Force appear to take a very restricted view of what qualifies for evidence. For a disease like prostate cancer, one of the few with really long survival times, and likely growing late-stage survival as a result of many new approved medical options, is overall and or prostate cancer specific survival a feasible end point for scoring the success of screening? If not, doesn’t sound thinking compel us to look for different kinds of evidence for the success of screening? (That suggests a catchy song lyric: “Lookin’ for evidence in all the wrong places.” Maybe I’ll give that a try.)

  6. Hi Sitemaster,

    I’m responding to your July 5 9:38 pm response to me (thanks as always) regarding that 10-15 year life expectancy yardstick, the topic of my July 5 9:24 PM post. Up front, yes, a better test would certainly help.

    I’m trying to visualize the impact of using that life expectancy yardstick to sort out the usefulness of screening in men aged 55 to 69 in good health. The potential downside would be that those with a life expectancy shorter than 10 years would be a lot less likely to be screened, if the guideline were widely followed. That’s the group where we would be blind to prostate cancer until it became metastatic, but the AUA line of thought, I take it, is that that group is small enough to be considered negligible, weighing the harms of screening in the balance. I would like to try to estimate the size of that group, but I cannot think of any way to approximate it at the moment. Any thoughts anyone?

    Here’s a tacked on thought re:

    REDUNDANCY IN PHRASE: “MEN AGES 55 TO 69 WHO ARE IN GOOD HEALTH AND HAVE MORE THAN A 10- TO 15-YEAR LIFE EXPECTANCY”.

    I’m not sure redundancy matter, but it might in our modeling and treatment decision guides. Here’s the thought: these days in the US, men in good health aged 69 have at least a 10-year life expectancy. Table 101, “Average Number of Years of Life Remaining by Sex and AGe: 1989 to 2005,” 128th edition of the “Statistical Abstract of the United States, 2009”, per the U.S. National Center for Health Statistics, reports that for age 70, average life expectancy, therefore whether in good health or not, for all men as of 2005 was 13.8 years, or a total of 83.8 years. Clearly the expectancy for men aged 70 in good health would be even higher than this average, and topping the range at 69 would have a negligible effect on the expectation based on the trend in the table. This expectation obviously exceeds ten years.

    For what it’s worth, it seems that men aged 55 to 69 in good health are all going to have a life expectancy of more than 10 years, barring a homicidal spouse or equivalent factor, making the phrase “in good health” redundant to the phrase “more than a 10 – 15 year life expectancy.”

    Perhaps the twin phrases improve communication with patients.

    Perhaps there is other value to including both phrases.

  7. THE AUA’S WALL CHART FOR PATIENTS

    I’m fairly comfortable with the wall chart, though I wish it put greater emphasis on the value of screening, a greater value which the AUA is not seeing due, apparently, to reliance on faulty interpretation of PLCO and ERSPC results. That said, this chart should guide some primary care doctors to a wiser course than they would have followed under guidance from the blundering U.S. Preventive Services Task Force.

    I considered my own circumstances at age 56 in December 1999 and tried to imagine how I would have reacted to this chart. Based on my father’s death from prostate cancer, I would have fallen into the group advised to talk to my health care provider, and I believe I would have selected screening as “A normal PSA test may put your mind at ease” to quote from the chart.

    Regarding the redundancy issue (4:47 PM post), the chart omits the “good health” aspect except for men with urinary problems and for men “70+” years old, where it advises men in “excellent health” to talk to their health care provider. I like the handling of the issue in the chart, preferring that version to the handling of health status in the FAQ (covers age and also “good health” in a redundant way), but the difference is probably too subtle to be consequential.

    Under “SHOULD I GET SCREENED FOR PROSTATE CANCER?”, there is no mention of the likely value of a PSA velocity of higher than 2.0 in assessing risk for men determined to be higher risk cases. Annual testing would help in assessing velocity, though at least three widely spaced data points appear preferable. This benefit of screening is probably still too controversial for any kind of mention in such a chart. (The D’Amico team initiated research on this.)

  8. Dear Jim:

    If you look at the AUA’s actual guideline it gives you all the reference data to the studies that the guideline is based on. You can’t base a guideline on data that don’t exist, which is exactly why the term “best available” evidence is used. Just because that evidence is unsatisfactory doesn’t make it “wrong.”

    There is a highly mistaken idea that prostate cancer is one of very few cancers that people live with for 20+ years after a diagnosis. This is in fact fallacious. There are many, many cancers that can take 20+ years from initial diagnosis to death. As with prostate cancer, there is usually a spectrum, with some people being completely curable (e.g., of melanoma when it is caught early) and others dying very fast (if they are unlucky enough to get a particularly aggressive form of that cancer that metastasizes early and fact (again, e.g., melanoma). Other cancers with this wide spectrum of subtypes and long progression times in many many cases can include breast cancer, myeloma, chronic lymphocytic leukemia, some subtypes of lymphoma, baldder cancer, and others. Prostate cancer is far from unique in this regard.

  9. I think the point is more about the implications for men aged 55-69 who are in poor health. Guideline writes don’t want to have to write “for men in poor health” because then one has to define that explicitly. By writing the phases the other way around, one escapes the need to be explicit about what is “poor health.”

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