The AUA guideline provides recommendations for prostate cancer screening based on a systematic review of evidence from 1995-2013. For men aged: - Under 40, screening is not recommended due to low cancer prevalence and harms outweighing benefits. - 40-54, screening is not routinely recommended as evidence of benefit is marginal compared to starting at 55 and harms are high. - 55-69, shared decision making is recommended to weigh benefits and harms of screening based on individual values and preferences. - 70+, screening is not routinely recommended due to small potential benefit and higher potential for harms. The guideline requires periodic updating as more evidence emerges on benefits of screening outside the ages of 55-69.

1. Detection of Prostate Cancer:
AUA Guideline

2. NONE
Disclosures

3. Peter Albertsen
Michael Barry
Ruth Etzioni
Stephen Freedland
Kirsten Greene
Lars Holmberg
Philip Kantoff
Badrinath Konety
David Penson
Anthony Zeitman
Panel Participants
AUA Staff:
Heddy Hubbard Michael Folmer
Erin Kirby Abid Khan
Patricia Lapera

4. BEST PRACTICE STATEMENT
Evaluation of PSA for detection, risk stratification,
management of prostate cancer
Not systematic literature review
Recommendations based on clinical experience and
expert opinion
Current Guideline Differs from PSA Best
Practice Statement (2009)

5.  Evidence based evaluation of prostate cancer
detection to reduce prostate cancer mortality
 Statements based on evidence rather than values,
opinion, or clinical experience
 Findings intended to assist the urologist in advising
an “average” risk man without symptoms about
prostate cancer screening
Guideline Purpose

6.  Systematic review of published studies relevant to
diagnosis/screening of prostate cancer from Jan
1995 to Feb 2013
 Digital rectal examination
 Serum and urine biomarkers alone/combination
 Imaging
 Genetics
 Prostate biopsy
 Shared decision making
Methodology: Literature Review

7. With the exception of PSA-based screening, there
was minimal evidence to assess pre defined
outcomes of interest using other tests –
324 eligible studies addressed:
•Prostate cancer incidence and mortality
•Quality of life
•Diagnostic accuracy
•Harms of testing
Methodology: Systematic Review

8. Framework: PSA Focused Guideline

9. Rating of Evidence Strength and Quality

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 unclear
Linking of Evidence to Statement Type

11. The panel did not go beyond the evidence in
formulating STATEMENTS
•Quality of the evidence
• Benefits of screening – moderate (B)
• Harms of screening – high (A)
Interpretation of Evidence

12. The panel evaluated the early detection of
prostate cancer in average risk men by
age, recognizing that the harm-benefit
ratio is highly age-dependent
• < 40yrs
• 40-54yrs
• 55-69yrs
• 70+yrs
Guideline Statement Organization

13. Recommend against PSA-based screening of
men under age 40yrs (Recommendation;
Evidence Strength: Grade C)
In this age group there is a low prevalence of
clinically detectable prostate cancer, no
evidence demonstrating a benefit for
screening, and likely the same harms of
screening as in other age groups
Guideline Statement 1: Age <40yrs

14. Screening as a routine is not recommended in men
between ages 40-54yrs at average risk
(Recommendation; Evidence Strength: Grade C)
The evidence for benefit is marginal when compared
to screening beginning at age 55yrs, and the quality
of evidence for harm is high
Guideline Statement 2: Age 40-54yrs

15. Men age 40-54yrs are often screened presuming that
they have the most to gain from treatment because
of an increased life expectancy
Low prevalence of fatal prostate cancer, long lead
times, and extended time at risk for harm from
treatment, all may lead to greater harm than benefit
Guideline Statement: Age 40-54yrs

16. For men younger than age 55yrs at higher
than average risk, decisions regarding
prostate cancer screening should be
individualized based on personal
preferences, and an informed discussion
regarding the uncertainty of benefit and the
harms of screening should take place prior to
a decision
Guideline Statement: Age 40-54yrs

17. The panel recommends shared decision making for
men age 55-69yrs considering PSA testing, and
proceeding based on a patient’s values and
preferences (Standard; Evidence Grade: B)
A decision to undergo screening must weigh the
benefit of preventing 1 prostate cancer death per
1000 screened over a decade vs the harms of
screening and treatment
Guideline Statement 3: Age 55-69yrs

18. Shared decision making should include a
discussion of a man’s life expectancy and
prostate cancer risk based on race and family
history, and the degree to which screening
might influence this risk
PSA-based screening should not be performed in
the absence of shared-decision making (e.g.,
health fairs, health system promotions,
community organizations)
Guideline Statement: Age 55-69yrs

19. A routine screening interval of 2yrs or more may be preferred
over annual screening in those men who have participated
in shared-decision making and chosen screening. As
compared to annual screening, it is expected that
screening intervals of 2yrs preserve the majority of benefits
and reduce over diagnosis and false positives (Option;
Evidence Grade: C)
Intervals for rescreening can be individualized by a baseline
PSA level and/or prior PSA history
Guideline Statement 4: Reducing Harms of
Screening

20. Recommend against routine PSA-based screening in
men age 70+ yrs, or in any patient with less than a 10-
15yr life expectancy (Recommendation; Evidence
Grade: C)
Some men over age 70yrs who are in excellent health
may benefit from prostate cancer screening
An absolute reduction in mortality while possible is likely
small, and the potential for harm high, or at least higher
than benefit
Guideline Statement 5: Age 70yrs and Above

21. For the older man who has chosen screening,
the panel suggests the following to reduce harm
• the use of higher PSA thresholds for
prostate biopsy (e.g., 10ng/ml)
• discontinuation of screening in men with
lower PSA levels (e.g. <3ng/ml)
Guideline Statement: Age 70yrs and Above

22. • Benefits from screening beyond a decade have yet to be
assessed in large RCT’s
• Absence of direct evidence for screening benefit outside the
age 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 than
PSA for primary screening
Guideline Requires Periodic Updating

23. The panel’s goal is to present an evidence
based approach to prostate cancer
detection that targets men most likely to
benefit, and improves the ratio of
benefit/harm
For more information, please attend:
Detection of Prostate Cancer and Castration Resistant
Prostate Cancer Course
May 6, Noon-1:30PM, San Diego CV 6C
Summary: AUA Guideline on Early Detection
of Prostate Cancer