New prostate cancer screening guidelines from AUA emphasize targeted patient screening

New guidelines from the American Urological Association (AUA) advise men aged 55 to 69 years who are considering prostate cancer screening to talk with their doctors about the benefits and harms of testing and proceed based on their personal values and preferences. The new guideline, which updates the Association's 2009 Best Practice Statement on Prostate-Specific Antigen (PSA), was announced during the 2013 AUA Annual Meeting in San Diego, California, held May 4-9, 2013. 

“The AUA believes that the new guidelines are the beginning of a targeted approach to prostate cancer screening compared to the one-size-fits-all approach done in the past, and in the future, new markers will allow an even more targeted approach. Oncology nurses should understand that men aged 55 to 69 years, or those at increased risk, should speak to their doctor about prostate cancer screening and the best treatment or management approach if diagnosed with the disease,” said panel chair H. Ballentine Carter, MD, Professor of Urology and Oncology at Johns Hopkins Medicine in Baltimore, Maryland, and Director, Division of Adult Urology at Brady Urological Institute in an interview.

Carter explained, “The new AUA guidelines were created by a systematic review of the most recent published literature on prostate cancer screening in accordance with the Institute of Medicine's standards for the development of treatment guidelines. The guidelines tighten the recommended age range that men should speak to their doctor about prostate cancer screening, targeting those who are most likely to benefit from testing and helping to reduce overdiagnosis and -treatment.”

The highest quality evidence for screening benefit (lower prostate cancer mortality) was in men aged 55 to 69 years screened at 2- to 4-year intervals; data demonstrated that one man per 1,000 screened will avert a prostate cancer death over a decade. However, over a lifetime, this benefit could be much greater. Furthermore, there are men outside this target age range (55 to 69 years) that could benefit from screening because they are at a higher risk of prostate cancer (race, family history, etc). These men should discuss their risk with their physicians and assess the benefits and risks of testing.
The guideline makes several specific statements. First, PSA screening in men younger than 40 years is not recommended. Next, routine screening in men aged 40 to 54 years at average risk is not recommended. For men aged 55 to 69 years, the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in one man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, shared decision-making is recommended for men aged 55 to 69 years that are considering PSA screening, and proceeding based on patients' values and preferences. 

The guidelines also state that, to reduce the harms of screening, a routine screening interval of 2 years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of 2 years preserve the majority of the benefits and reduce overdiagnosis and false positives. Finally, routine PSA screening is not recommended in men over age 70 or any man with less than a 10- to 15-year life expectancy. 
“The best available evidence suggests that following these guidelines will lead to an improved benefit-to-harm ratio,” said Carter.

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