In a significant about-face, the American Urological Association (AUA) recently published clinical guidance(www.auanet.org) that recommends against performing all routine prostate-specific antigen (PSA)-based screening for prostate cancer, as well as all screening in men older than 70, men younger than 40 and average-risk men ages 40-54.
Doug Campos-Outcalt, M.D., M.P.A., of Phoenix, the AAFP liaison to the U.S. Preventive Services Task Force (USPSTF), said the move brings the AUA much more in line with AAFP and USPSTF recommendations against performing PSA screening in asymptomatic men regardless of age.
"This is pretty big," said Campos-Outcalt. "The AUA was very much against the official USPSTF/AAFP universal recommendation against PSA screening when it was released.
"I think their guideline committee deserves a lot of praise. It is not easy to buck common practice within your own specialty."
Campos-Outcalt pointed out that there is now agreement between the AUA, the USPSTF and the AAFP that PSA screening should not be done as a routine test at all.
- New guidelines from the American Urological Association (AUA) recommend against performing all routine prostate-specific antigen (PSA)-based screening for prostate cancer, as well as all screening in men older than 70, men younger than 40 and average-risk men ages 40-54.
- The AUA now calls for physicians to discuss "the limited potential benefits and substantial harms of screening for prostate cancer" with high-risk men (i.e., those with a strong family history of prostate cancer) ages 40-54 and all men ages 55-69 and encourages physicians to perform screening only if a patient expresses a clear preference to do so.
- The new guidance moves the AUA significantly closer to the position against all PSA screening set out last year by the AAFP and the U.S. Preventive Services Task Force.
"That's significant, because health fairs, hospital screening month events, all of those things should not (offer PSA screening)," he said. "The three groups also are in agreement that men after age 70 should not have it done, nor should men before the age of 40.
"And lastly, they are in agreement that average-risk men 40-54 shouldn't have it done. That's quite a change."
Disagreement remains regarding high-risk men (i.e., those with a strong family history of prostate cancer) ages 40-54 and all men ages 55-69. The AUA now calls for physicians to discuss "the limited potential benefits and substantial harms of screening for prostate cancer" with these patients and encourages doctors to perform screening only if a patient expresses a clear preference to do so.
"For men ages 55-69 years the (AUA guideline) panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment," the recommendation said.
"The difference is that the USPSTF and AAFP say the test shouldn't be used at all," Campos-Outcalt said. "The AUA says that the test should be a man's decision after discussion and a full understanding of the benefits and the harms. So the key for me is that any discussion with patients is worth documenting, but I still believe it is defensible not to use the test at all."
Campos-Outcalt said the one real criticism he has regarding the guideline is that the AUA did not, in his opinion, do a thorough enough job cataloguing the harms of PSA screening.
"They do a pretty good job of cataloguing the benefit, but they don't describe the complete litany of harms," he said. "The guideline offers a table on harms (Table 3), but it doesn't list the deaths that occur from the treatments. It lists 'overdiagnosis,' but does not include what the significance of that is, which means that many of these (cancers) are treated, and the treatment can lead to death. That's not defined clearly here."
At the end of the day, however, the new guideline should help family physicians discuss the issue with their patients, said Campos-Outcalt.
"Frankly, if you are sitting with a man who doesn't have a strong family history of prostate cancer, I can't see how -- after you discuss the potential benefits and all of the potential harms -- that many men are going to choose screening," he said.