Implications of the New AUA Guidelines on Prostate Cancer Detection in the U.S.

Abstract

In 2012, the U.S. Preventive Services Task Force (USPSTF) issued a blanket "D" recommendation against all prostate-specific antigen (PSA)-based early detection efforts for prostate cancer, reflecting critical misinterpretations of the major evidence regarding benefits and harms of such testing. Against the backdrop of the ensuing controversy, in 2013 the American Urological Association (AUA) published a new, methodologically rigorous guideline. This guideline recommended that men aged 55-69 be offered biennial screening in the setting of shared decision-making, that men under 40 or over 69 years of age should not be screened routinely, and that evidence was insufficient to recommend screening for men aged 40-54 years. While it has received criticism with regard to the age-based recommendations, the AUA guideline reflects a far better and more balanced presentation of the available evidence than the USPSTF statement. However, because the USPSTF is far more influential than the AUA among primary care providers, the ultimate impact of the new AUA guideline on practice patterns may be limited. Optimizing early detection practices should involve consensusbuilding incorporating both primary care and specialist input, with the goals of minimizing overtreatment of low-risk disease while continuing to reduce prostate cancer mortality rates through early detection and aggressive management of highrisk disease.

Prostate Cancer Screening and the Associated Controversy

“…44,45 A major argument by the USPSTF was that the PLCO trial failed to demonstrate a significant reduction in prostate cancer mortality in the screened group compared with the control group; however, a critical flaw of the PLCO trial was that it was not a true comparison between a screened population and an unscreened population. Before the study, 44% of all enrollees, regardless of whether they were randomized ultimately into the screening group or the control group, had at least 1 PSA test before enrollment.…”

Applying precision medicine to the active surveillance of prostate cancer

“…10 However, this blanket recommendation has not been without controversy, given the nuances of trial design, population characteristics, and subanalyses of what to our knowledge are the 2 most methodologically sound studies of PSA screening to date (the Prostate, Lung, Colorectal and Ovarian [PLCO] Cancer Screening Trial and European Randomized Study of Screening for Prostate Cancer ERPC). [11][12][13] In addition, worries regarding an increase in avoidable cancer deaths in the absence of screening remain. 14 Nevertheless, the current paradigm is to avoid overtreatment simply by screening no one.…”

“…These issues are why, in part, the US Preventive Services Task Force determined PSA screening to be a grade D recommendation, stating that the risks of screening outweigh the benefits . However, this blanket recommendation has not been without controversy, given the nuances of trial design, population characteristics, and subanalyses of what to our knowledge are the 2 most methodologically sound studies of PSA screening to date (the Prostate, Lung, Colorectal and Ovarian [PLCO] Cancer Screening Trial and European Randomized Study of Screening for Prostate Cancer ERPC) . In addition, worries regarding an increase in avoidable cancer deaths in the absence of screening remain .…”

Sociodemographic and Clinical Predictors of Switching to Active Treatment among a Large, Ethnically Diverse Cohort of Men with Low Risk Prostate Cancer on Observational Management

“…1 Current US guidelines recommend observational management, AS or watchful waiting (WW), as strategies for men who are at low-risk of disease progression, 2–4 thereby avoiding active treatment (AT) unless clinical measures indicate disease progression or the patient requests AT. 5, 6 Results from prostate-specific antigen (PSA) testing and repeat biopsies are used to determine PCa progression and prompt cessation of observational management.…”