Neil Skolnik, MD
DISCLOSURES | May 22, 2024
I’m Dr Neil Skolnik, and today I’m going to talk about the American Urological Association’s (AUA’s) guideline on the early detection of prostate cancer. This guideline gives us the opportunity to revisit prostate cancer screening with prostate-specific antigen (PSA).
Before I go over the recommendations, I want to remind people about the context in which this recommendation was released. An enormous range of recommendations exist from different organizations recommending different things. On one end of the spectrum is the American Academy of Family Physicians, which does not recommend routinely discussing PSA-based screening if the patient does not request it, and goes on to say that for men 55-69 years of age who are considering periodic prostate cancer screening, physicians should discuss the risks and benefits and engage in a shared decision-making that enables an informed choice. They give that a grade C recommendation, and they recommend against screening men older than 70.
A guideline from BMJ gives “a weak recommendation against offering systematic PSA screening.” The American College of Physicians recommends that clinicians inform men 50-69 years of age about the limited potential benefits and the substantial harms of screening for prostate cancer, and goes on to state that screening should not be done in men under 50 or over the age of 69.
This is the context in which the AUA guideline has come out. As is true of all the guidelines, the AUA guideline is explicit about the challenge inherent in PSA testing, which is to identify clinically significant prostate cancer while minimizing the harm caused by detecting cancers that would never otherwise have become manifest.
Let me go over the recommendations. I think you’ll see some helpful information, and you’ll also note some obvious differences in the recommendations between the AUA and other groups. For starters, all the groups agree on (and the AUA guidelines emphasize) the importance of shared decision making because prostate cancer screening is truly a preference-sensitive decision. Essentially, this means, which do you fear more: the risk for prostate cancer, or the risk for side effects of treating a cancer that may never have caused you a problem?
A critically important recommendation is that for people with newly elevated PSA levels, clinicians should repeat the PSA in a few months before any further screening or diagnostic testing is done. This is because 25%-40% of elevated PSA levels are normal on retesting.
The guidelines then discuss the issue of what level of PSA should be considered elevated, because PSA normally increases with age. Although they don’t give specific recommendations here, they say that studies that identify age-specific thresholds for elevated PSA use ≥ 2.5 ng/mL for people in their 40s, slowly increasing up to 6.5 ng/mL for people in their 70s. Most of us in primary care won’t remember the exact thresholds, but it’s important to recognize that for younger men, the usual number of 4 ng/mL is not a line in the sand, and you may think about referring at a lower PSA level.
Next up, the guidelines give a conditional recommendation that we may begin prostate cancer screening and offer a baseline PSA to average-risk men aged 45-50. For people at increased risk for prostate cancer (Black ancestry, strong family history, or other strong risk factors), the AUA makes a strong recommendation that screening should be offered beginning at age 40-45 years.
After a first test, the guidelines strongly recommend offering regular prostate cancer screening every 2-4 years from age 50-69. Again, I want to point out that the interval of every 2-4 years provides helpful guidance if our patient chooses to proceed with screening. The guidelines suggest that the age to discontinue screening is flexible and to think about this at age 70, because the risk for overdiagnosis of non–clinically significant prostate cancers increases with age.
Let me now point out some differences from the US Preventive Services Task Force (USPSTF) 2018 recommendations, which are in the process of being updated. Where the AUA recommends to start offering screening at age 45 (or 40 for those at high risk), and then screen every 2 to 4 years from age 50-69, the USPSTF gives a grade C recommendation to starting to discuss screening at age 55 and continue through age 69, and then it recommends not screening men above age 70. Although the USPSTF acknowledges the increased risk in some groups, including men with a family history of prostate cancer and African American men, for those two groups, they say (and this is a quote) that “the USPSTF is not able to make a separate, specific recommendation on PSA-based screening.”
To round out our comparisons, the American Cancer Society recommends discussing screening starting at age 50 for those at average risk and 45 for those at high risk.
Finally, the AUA guidelines clarified that a rise in PSA level over time (often referred to as the PSA velocity) should not be used as the sole indication for further evaluation of prostate cancer.
This is a lot of conflicting information among different organizations, and that information has changed over time. See my earlier essay in JAMA Internal Medicine on this issue. This is really important information to understand. It comes up all the time with our patients.
I’m interested in your thoughts on this topic. Please leave them in the comments section below.
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