AUA best practice statement supports individualized PSA testing, baseline readings

American Urological Association Annual Meeting

At its annual meeting today, the American Urological Association issued a new best practice statement on prostate cancer screening that recommends PSA testing be individualized among patients and that all men get a baseline reading at age 40. This recommendation is in contrast to recommendations issued by the U.S. Preventive Services Task Force, the National Comprehensive Cancer Network and the American Cancer Society.

“The single most important message of this statement is that prostate cancer testing is an individual decision that patients of any age should make in conjunction with their physicians and urologists. There is no single standard that applies to all men, nor should there be at this time,” said Peter Carroll, MD, chair of the panel that developed the statement and Ken and Donna Derr-Chevron Distinguished Professor at the University of California, San Francisco.

The new guidelines recommend PSA testing for any man aged 40 or older, stating that an above average PSA score at age 40 is a strong predictor of developing the disease later in life. In addition, the association recommends that men who wish to be screened have a digital rectal exam as well as PSA testing. The results of these two tests should be interpreted with information about family history, age, overall health and ethnicity in order to determine an individual’s risk for prostate cancer.

Furthermore, the AUA does not recommend a PSA value at which a biopsy should be recommended. Instead, the decision to biopsy should take into account individual characteristics listed above plus free and total PSA, PSA velocity and density, previous biopsy history and comorbidities.

Finally, the statement emphasized that not all prostate cancers require active treatment and not all cancers are life threatening.

The new statement also addresses the results of two major studies on PSA testing recently published in The New England Journal of Medicine.

In a statement issued in March, John Barry, MD, president of the American Urological Association said, “These studies, as well as the 2008 U.S. Preventive Services Task Force recommendation that men stop PSA testing after the age of 75, have potential for harm if they are not explained clearly to patients or reviewed in the context of the full debate on PSA. It is the opinion of the AUA that the PSA test is a valuable screening tool that saves lives — and men with concerns about elevated PSA scores should consult their urologists about next steps.”

The AUA’s newly issued statement also clarifies a number of key points about the use of PSA in treatment selection and post-treatment follow-up of prostate cancer patients:

Serum PSA predicts the response of prostate cancer to local therapy.
Routine use of a bone scan is not required for staging asymptomatic men with clinically localized prostate cancer when their PSA level is ≤20.0 ng/mL.
CT or MRI scans may be considered for the staging of men with high-risk clinically localized prostate cancer when the PSA is >20.0 ng/mL or when locally advanced or when the Gleason score is ≥8.
Pelvic lymph node dissection for clinically localized prostate cancer may not be necessary if the PSA is <10.0 ng/mL and the Gleason score is ≤6.
Periodic PSA determinations should be offered to detect disease recurrence.
Serum PSA should decrease and remain at undetectable levels after radical prostatectomy.
Serum PSA should fall to a low level following radiation therapy, high intensity-focused ultrasound and cryotherapy and should not rise on successive occasions.
PSA nadir after androgen suppression therapy predicts mortality.
Bone scans are indicated for the detection of metastases following initial treatment for localized disease, but the PSA level that should prompt a bone scan is uncertain. Additional important prognostic information can be obtained by evaluation of PSA kinetics.
The kinetics of PSA rise after local therapy for prostate cancer can help distinguish between local and distant recurrence. – by Leah Lawrence

There is emerging evidence from studies done in Sweden that a single PSA determination in your 40s helps determine your lifetime risk of developing prostate cancer. This is relatively new data and it will allow us to tailor our screenings strategies. It's clear from that data and from the Prostate Cancer Week Awareness campaign over the last two decades in the United States, and the two studies published in the NEJM — the PLCO and the European screening trial — that not everybody needs to be screened every year. So starting with a baseline PSA at 40 gives you some idea what your future risk is and how often you need to be screened.
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– Eric Klein, MD

Chairman of the Glickman Urological & Kidney Institute
Cleveland Clinic President-Elect of the Society of Urologic Oncology