Problems with the AUA Approach
In my opinion, the AUA guidelines are based on incomplete data and inaccurate estimates of the benefits and risks of PSA testing. The AUA charged its Guidelines Panel with developing evidence-based guidelines grounded in the results of prospective randomized clinical trials. But, the Roundtable correctly noted there is not much reliable evidence from trials. Also, these trials do not reveal true information about absolute risks and benefits of screening over a lifetime.
Guidelines panels take a societal perspective in making health-care policy. They are willing to accept some unnecessary suffering and death from cancer to reduce the potential harms of overtreatment. In contrast, most physicians who are responsible for the care of individual patients have a different perspective. They believe that cancer should be detected early, and they determine which patients need immediate treatment using patient preferences and sound clinical judgment.
Moreover, in weighing benefits of PSA testing, the Panel focused solely on prostate cancer death without considering suffering from advanced cancer. However, avoiding metastases shifts the balance of harms and benefits; men diagnosed with more advanced diseases ultimately require more treatments and have more side effects.
In weighing the harms of testing for prostate cancer, the Panel cast a net over a variety of side effects of PSA testing, biopsy or prostate cancer treatment that range from minor to serious. None of these side effects reach the extreme of death from prostate cancer.
Problems with the Guidelines
Screening Men in Their 40s
The AUA does not recommend screening men under age 55 who have an average risk of prostate cancer. However, the primary objective of screening men in their 40s is to establish a baseline PSA, which helps assess a man’s risk for the subsequent development of life-threatening prostate cancer. A higher baseline PSA in a man’s 40s is a strong risk factor, as is being African-American or having a family history of prostate cancer. It is not possible to make a full assessment of which patients are actually at high risk without having a patient’s baseline PSA from his 40s or early 50s.
“The AUA guidelines are a step in the wrong direction for patient-centered care that may deprive many men of the opportunity to pursue shared decision-making. A more forward-looking approach is needed.”– William J. Catalona, MD
Age 55 is Too Late to Start Screening
The AUA does not recommend routine screening prior to age 55 simply because this has not been tested in a prospective randomized clinical trial. There is no evidence from trials concerning benefits or harms of PSA testing in men younger than 55 years old. But, starting at age 55 is really too late. Although the fine print in the AUA guidance document explains that the AUA does not recommend against PSA testing for men 40 to 55 years old, the actual guidelines statement uses the language, “we do not recommend.” It should say, “there is insufficient evidence to recommend for or against early detection in men younger than 55.” Because of this, the AUA Guidelines were frequently misrepresented in the popular media with headlines such as “Urology group stops recommending routine PSA test,” which appeared in USA Today.
Two Years May Be Too Long to Wait
The AUA recommends a 2-year interval between screening tests, but 2 years may be enough time for the most aggressive cancers to spread. Lethal cancers grow rapidly, and testing should be done frequently to prevent late detection of potentially dangerous cancers.
Age 70 May Be Too Early to Stop Screening
The AUA does not recommend routine PSA testing in men older than age 69. However, older men have a greater risk of aggressive disease. Age 70 is too young to stop testing in otherwise healthy men who have a 10-15 year or more life expectancy. Therefore, PSA testing in men over 70 years of age should be performed on an individual basis with shared decision-making between physicians and patients.