In this interview, Dr. H. Ballentine Carter clarifies some misconceptions about the AUA PSA guideline and explains how it will benefit patients.
A new AUA guideline that recommends against routine prostate cancer screening in men under age 55 and over age 69 came as a surprise to many, but the guideline is not summarily dismissing the use of the PSA test in these populations, says H. Ballentine Carter, MD, guideline panel chair. In this interview, Dr. Carter clarifies some misconceptions about the guideline and explains how it will benefit patients. Dr. Carter is professor of urology and oncology at the James Buchanan Brady Urological Institute at Johns Hopkins University, Baltimore. He was interviewed by Urology Times Editorial Consultant J. Brantley Thrasher, MD, professor and chair of urology at the University of Kansas Medical Center, Kansas City.
How does the new guideline differ from the best practice statement that the AUA released 4 years ago?
Dr. CarterThe best practice statement, which came out in 2009, addressed PSA testing not only for diagnosis but also for risk stratification and for management of prostate cancer. The guideline, which was recently published in the Journal of Urology (2013; 190:419-26), focuses on the early detection of prostate cancer in asymptomatic, average-risk men. Additionally, the best practice statement did not use a formal systematic literature review like the current guideline did. Finally, the best practice statement often based recommendations on opinions and values; it was not just evidence based. It was more of a consensus-based document than the new guideline is.
I’ve heard it said that the new AUA guideline is just a reaction to the U.S. Preventive Services Task Force recommendations. Is that true?
Definitely not. Our process began 2 years ago at the AUA annual meeting in Washington, when the AUA asked for the development of an evidence-based guideline on prostate cancer detection. It was 1 year later-at the AUA annual meeting in Atlanta-that the U.S. Preventive Services Task Force issued their grade D recommendation on prostate cancer screening. We were already working on a guideline 1 year before the USPSTF recommendation.
Please explain the differences in your panel’s findings for the age group 55 to 69 years and the USPSTF recommendations for the same age group.
The task force concluded, based on their review of the evidence, that the service, namely PSA testing, should be discouraged. They said it should be discouraged for all age groups and all races; in other words, do not use this test. The current AUA guideline is very different in that we are not discouraging the use of the PSA test. We identified a group of individuals, ages 55 to 69, where there is the best evidence that benefits may outweigh harms. In identifying that group, we believe we should be focusing our efforts on that group because they are the men most likely to benefit. You could call it targeted screening.
We did not say that there were men in other age groups who will not benefit. There are men in other age groups who may benefit, but this is the whole process of shared decision making that needs to take place between the patient and physician.
Focusing on that same age group, are you saying that rather than giving screening a grade D recommendation, you would have given a grade C?
Yes, we would have given it a C, which recommends selectively offering a service based on professional judgment and patient preferences. We would, as we did, emphasize shared decision making for the age group 55 to 69.
Dr. ThrasherThere are some younger patients, those 40 to 55, who may have high-risk features, such as family history or African-American race. Is this guideline discouraging a conversation about prostate cancer screening in those men?
This is a complicated issue, because we know that we can test at an earlier age and identify some men based on their PSA level who are at higher risk of developing prostate cancer later on. That’s a different question than asking, if we were to detect it in a 40-year-old versus waiting until they reach age 55, have we improved any health outcome? Our problem in struggling with that question was that we do not have any high-level evidence that if we start screening early, we are going to improve health outcomes.
Having said that, in the younger man who is at higher risk-one who has a family history or is African-American-we strongly believe that shared decision making should take place between that patient and his physician, and then they should decide together whether screening is appropriate.
So the AUA is not summarily dismissing PSA in that group of patients?
Absolutely not. There has been a misunderstanding about this, and the word that should be emphasized is “routine.” We are not recommending routine screening of average-risk men ages 40 to 54 years.
Did the panel address possibly extending the time between screenings?
We did. We felt that there was evidence to suggest that every-other-year screening would be as effective as annual screening in terms of benefits, but also would reduce harms by reducing the number of false-positive tests and the number of unnecessary biopsies. We did recommend that one way to reduce harm was to increase the interval between tests.
Moving away from the guideline per se, let’s talk about some of the complicated issues that this guideline is going to bring up. One question that has been raised fairly often by urologists is what to do with the man who is outside the recommended screening age group. Let’s say, for example, I’ve been following a 70-year-old man in my practice for 5 or 6 years who has a PSA of 7.0 ng/mL and has had two previous biopsies. He has this elevated PSA, but I haven’t found a cancer yet and I’m still concerned. How do you recommend we handle those types of patients?
That is a very good question, and I don’t think there is a one-size-fits-all answer. I think the patient and physician need to sit down together. The physician will want to know what those biopsies showed. Was there PIN, and was there atypia? The physician will want to know the patient’s PSA history and whether the biopsy was triggered because there were PSA levels that were a little higher and are now much lower. And the physician needs to know the comorbidity of this individual; if he has had five heart attacks, is obese, and has diabetes, maybe it’s time not to follow that patient so carefully. I think urologists are very good at determining whether or not a person is going to benefit from treatment, and I think that’s an individual decision.
Another issue is that many of the people making these decisions are primary care physicians, and they may be saying that outside of these screening ranges, we’re not even going to get PSAs. To clarify, it sounds like you’re recommending a conversation with a 70-year-old man whom you are still concerned about and also a younger patient on the other side of that curve. But for the group of men who have very normal PSAs for years, would you agree that you can tell them there is no need to continue screening?
I totally agree. I think the message is not, “You are too old, you don’t need screening anymore.” Instead, the message is, “You have maintained a low PSA level all your life, you are now 75, and you have beaten all the odds-congratulations.”
Do you think the AUA or the guideline is discarding PSA? In other words, since we need a better screening test, are we saying, let’s just throw the baby out with the bathwater?
No, I don’t. PSA is a relatively good test, and I think this guideline is the beginning of what I would call targeted screening. We are identifying those men who are most likely to benefit, and as time goes by, we are going to have other tests, be they genetic tests, blood tests, or urine tests, that are going to help us better target those men who are most likely to benefit.
Do you think the guideline will help or hurt the AUA’s credibility in that it’s such a radical departure from the previous recommendation to start screening at age 40?
I think this is going to be a very positive step for the AUA, because we will be perceived as individuals who very carefully looked at the evidence and are trying to do what’s right in terms of reducing the harms of screening. We are all aware that there are harms and obviously potential benefits of screening, and we are trying to shift that ratio so that there is more benefit than harm.
One of the principal concerns we’ve heard about so often has been infectious complications from transrectal ultrasound and biopsies and the fact that those complications are increasing. Do you think another potential benefit of the guideline may be avoiding some of those unnecessary biopsies and potential complications?
Absolutely. I think this is an approach-call it targeted screening or more focused screening-that will lead to a reduction in unnecessary biopsies and a reduction in the complications of biopsies.
Are there other areas of the guideline that you have had to field questions about and would like to clarify?
One additional area that the panel felt fairly strongly about was mass screening by hospital systems, churches, and other organizations. The panel determined that outside the context of shared decision making, if a man is not going to hear about the potential benefits and harms of screening, then routine PSA testing should not be done.
We have all heard that we need to have a discussion with the patient. One of the problems has been in very busy practices where physicians say they don’t have time for that. Now that we have the evidence, do you see this as an opportunity to distribute this information in a publication or other format for patients?
Yes. There are decision support tools that help patients understand what the benefits and harms of screening are. There’s an entire science around how to communicate benefit and harm, and the AUA certainly can be a big part of that. The American Society of Clinical Oncology has a very nice decision support tool. The AUA is also putting a great deal of effort into communicating the potential harms and benefits of prostate cancer screening with primary care physicians and patients, using print and online media.UT
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