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  1. 1. Detection of Prostate Cancer:AUA Guideline
  2. 2. NONEDisclosures
  3. 3. Peter AlbertsenMichael BarryRuth EtzioniStephen FreedlandKirsten GreeneLars HolmbergPhilip KantoffBadrinath KonetyDavid PensonAnthony ZeitmanPanel ParticipantsAUA Staff:Heddy Hubbard Michael FolmerErin Kirby Abid KhanPatricia Lapera
  4. 4. BEST PRACTICE STATEMENTEvaluation of PSA for detection, risk stratification,management of prostate cancerNot systematic literature reviewRecommendations based on clinical experience andexpert opinionCurrent Guideline Differs from PSA BestPractice Statement (2009)
  5. 5.  Evidence based evaluation of prostate cancerdetection to reduce prostate cancer mortality Statements based on evidence rather than values,opinion, or clinical experience Findings intended to assist the urologist in advisingan “average” risk man without symptoms aboutprostate cancer screeningGuideline Purpose
  6. 6.  Systematic review of published studies relevant todiagnosis/screening of prostate cancer from Jan1995 to Feb 2013 Digital rectal examination Serum and urine biomarkers alone/combination Imaging Genetics Prostate biopsy Shared decision makingMethodology: Literature Review
  7. 7. With the exception of PSA-based screening, therewas minimal evidence to assess pre definedoutcomes of interest using other tests –324 eligible studies addressed:•Prostate cancer incidence and mortality•Quality of life•Diagnostic accuracy•Harms of testingMethodology: Systematic Review
  8. 8. Framework: PSA Focused Guideline
  9. 9. Rating of Evidence Strength and Quality
  10. 10. • Standard (evidence level A/B)Benefits are >or< than the harms• Recommendation (evidence level C)Benefits are >or< than the harms• Option (evidence level A-C)Benefits = harms or balance is unclearLinking of Evidence to Statement Type
  11. 11. The panel did not go beyond the evidence informulating STATEMENTS•Quality of the evidence• Benefits of screening – moderate (B)• Harms of screening – high (A)Interpretation of Evidence
  12. 12. The panel evaluated the early detection ofprostate cancer in average risk men byage, recognizing that the harm-benefitratio is highly age-dependent• < 40yrs• 40-54yrs• 55-69yrs• 70+yrsGuideline Statement Organization
  13. 13. Recommend against PSA-based screening ofmen under age 40yrs (Recommendation;Evidence Strength: Grade C)In this age group there is a low prevalence ofclinically detectable prostate cancer, noevidence demonstrating a benefit forscreening, and likely the same harms ofscreening as in other age groupsGuideline Statement 1: Age <40yrs
  14. 14. Screening as a routine is not recommended in menbetween ages 40-54yrs at average risk(Recommendation; Evidence Strength: Grade C)The evidence for benefit is marginal when comparedto screening beginning at age 55yrs, and the qualityof evidence for harm is highGuideline Statement 2: Age 40-54yrs
  15. 15. Men age 40-54yrs are often screened presuming thatthey have the most to gain from treatment becauseof an increased life expectancyLow prevalence of fatal prostate cancer, long leadtimes, and extended time at risk for harm fromtreatment, all may lead to greater harm than benefitGuideline Statement: Age 40-54yrs
  16. 16. For men younger than age 55yrs at higherthan average risk, decisions regardingprostate cancer screening should beindividualized based on personalpreferences, and an informed discussionregarding the uncertainty of benefit and theharms of screening should take place prior toa decisionGuideline Statement: Age 40-54yrs
  17. 17. The panel recommends shared decision making formen age 55-69yrs considering PSA testing, andproceeding based on a patient’s values andpreferences (Standard; Evidence Grade: B)A decision to undergo screening must weigh thebenefit of preventing 1 prostate cancer death per1000 screened over a decade vs the harms ofscreening and treatmentGuideline Statement 3: Age 55-69yrs
  18. 18. Shared decision making should include adiscussion of a man’s life expectancy andprostate cancer risk based on race and familyhistory, and the degree to which screeningmight influence this riskPSA-based screening should not be performed inthe absence of shared-decision making (e.g.,health fairs, health system promotions,community organizations)Guideline Statement: Age 55-69yrs
  19. 19. A routine screening interval of 2yrs or more may be preferredover annual screening in those men who have participatedin shared-decision making and chosen screening. Ascompared to annual screening, it is expected thatscreening intervals of 2yrs preserve the majority of benefitsand reduce over diagnosis and false positives (Option;Evidence Grade: C)Intervals for rescreening can be individualized by a baselinePSA level and/or prior PSA historyGuideline Statement 4: Reducing Harms ofScreening
  20. 20. Recommend against routine PSA-based screening inmen age 70+ yrs, or in any patient with less than a 10-15yr life expectancy (Recommendation; EvidenceGrade: C)Some men over age 70yrs who are in excellent healthmay benefit from prostate cancer screeningAn absolute reduction in mortality while possible is likelysmall, and the potential for harm high, or at least higherthan benefitGuideline Statement 5: Age 70yrs and Above
  21. 21. For the older man who has chosen screening,the panel suggests the following to reduce harm• the use of higher PSA thresholds forprostate biopsy (e.g., 10ng/ml)• discontinuation of screening in men withlower PSA levels (e.g. <3ng/ml)Guideline Statement: Age 70yrs and Above
  22. 22. • Benefits from screening beyond a decade have yet to beassessed in large RCT’s• Absence of direct evidence for screening benefit outside theage range 55-69yrs, non-Caucasians, positive family history• Ideal approach to serial PSA testing is unknown• Absence of direct evidence for a benefit of tests other thanPSA for primary screeningGuideline Requires Periodic Updating
  23. 23. The panel’s goal is to present an evidencebased approach to prostate cancerdetection that targets men most likely tobenefit, and improves the ratio ofbenefit/harmFor more information, please attend:Detection of Prostate Cancer and Castration ResistantProstate Cancer CourseMay 6, Noon-1:30PM, San Diego CV 6CSummary: AUA Guideline on Early Detectionof Prostate Cancer