Quest Winter 2013 : Page 1

A Publication of Dr. William J. Catalona Early Detection Worldwide Q uest Winter 2013 • Volume 21, Number 3 and the Urological Research Foundation early detection reduces the number of men dying from prostate cancer and developing metastatic disease, and PSA testing is a key element of screening. introduction of PSA testing 20 years ago. The authors wrote that an important goal for early detection is to maintain these survival rate gains while minimizing the harms associated with overdiagnosis and overtreatment. International Prostate Cancer Screening Recommendations Recognize Importance of PSA Testing R Melbourne Consensus New EAU Guidelines Statement The updated EAU guidelines Experts at the Prostate emphasized early detection of prostate Cancer World Congress in cancer through an individualized, risk-Melbourne, Australia, adapted approach rather than created a consensus widespread mass screening. Baseline statement on PSA testing to PSA testing is an integral component of We need a forward-looking approach to early detection. address the conflicting the guidelines, as is identifying relevant ecent prostate cancer screening recommendations of various urological risk factors that can be used to classify recommendations from the US groups. The statement highlighted the patients into risk groups. Preventive Services Task Force importance of shared decision-making See page 2 for summaries of the (USPSTF) and the American Urological and the significant improvement in Melbourne Consensus Statement and the Association (AUA) suggested that PSA prostate cancer survival rates since the EAU Guidelines. testing for prostate cancer should be restricted in certain age groups or A Forward-Looking Approach by Dr. William J. Catalona stopped altogether, resulting in different decisions… guidelines should y recommending that PSA testing confusion regarding the role of PSA avoid recommending for or against PSA should be abandoned completely or testing in the early detection of screening , rather we should recommend restricted, the USPSTF and the AUA prostate cancer. Consequently, many a shared decision process that includes guidelines are a step in the wrong primary care physicians and internists assessing patients’ feelings about what direction for patient-centered care. If are no longer ordering routine PSA they could go through after screening.” 1 widely implemented, these guidelines tests in their patients. In the absence of shared decision-would deprive many men of the New International Guidelines making, patients are more than twice opportunity to pursue shared decision-The latest screening as likely not to get tested. The future making about possibly life-saving PSA recommendations released by experts will bear out that PSA screening testing. A more forward-looking at the Prostate Cancer World Congress greatly reduces suffering and death approach is needed. As stated by Dr. and the European Association of from prostate cancer. The benefits far Harold Sox, “Weighing the pros and Urology (EAU) offered a different outweigh the harms. cons…is an individual process, and 1 Sox HC. N Engl J Med. 2012; 367:669-71 perspective. They emphasized that different well-informed men will make ©photo by Dan Oldfield B

EARLY DETECTION WORLDWIDE

International Prostate Cancer Screening Recommendations Recognize Importance of PSA Testing

Recent prostate cancer screening recommendations from the US Preventive Services Task Force (USPSTF) and the American Urological Association (AUA) suggested that PSA testing for prostate cancer should be restricted in certain age groups or stopped altogether, resulting in confusion regarding the role of PSA testing in the early detection of prostate cancer. Consequently, many primary care physicians and internists are no longer ordering routine PSA tests in their patients.

New International Guidelines
The latest screening recommendations released by experts at the Prostate Cancer World Congress and the European Association of Urology (EAU) offered a different perspective. They emphasized that early detection reduces the number of men dying from prostate cancer and developing metastatic disease, and PSA testing is a key element of screening.

Melbourne Consensus Statement
Experts at the Prostate Cancer World Congress in Melbourne, Australia, created a consensus statement on PSA testing to address the conflicting recommendations of various urological groups. The statement highlighted the importance of shared decision-making and the significant improvement in prostate cancer survival rates since the introduction of PSA testing 20 years ago. The authors wrote that an important goal for early detection is to maintain these survival rate gains while minimizing the harms associated with overdiagnosis and overtreatment.

New EAU Guidelines
The updated EAU guidelines emphasized early detection of prostate cancer through an individualized, riskadapted approach rather than widespread mass screening. Baseline PSA testing is an integral component of the guidelines, as is identifying relevant risk factors that can be used to classify patients into risk groups.

See page 2 for summaries of the Melbourne Consensus Statement and the EAU Guidelines.

Melbourne Consensus Statement
-PSA testing for men ages 50-69 reduces deaths and frequency of metastatic prostate cancer
The authors recommend shared decision-making rather than routine population-based screening.

-Prostate cancer diagnosis needs to be uncoupled from treatment
Active surveillance strategies need to be standardized and validated internationally to ensure the safety of this treatment approach.

-PSA testing is part of the approach to early detection
Variables such as digital rectal examinations, prostate volume, family history, ethnicity and risk prediction models can help determine a man’s risk level. New tools such as the prostate health index (PHI) test and further developments of biomarkers may also enhance risk prediction.

-A baseline PSA is useful for predicting future risk of prostate cancer
The higher a man’s baseline is above the median (0.5–0.7 ng/ml at 40- 49 years), the greater his risk of later developing life-threatening prostate cancer.

-Men with a life expectancy of more than 10 years may still benefit from PSA testing
Individualized assessment, rather than age alone, should determine if PSA testing for an older man would be useful.

The Melbourne Consensus Statement was published online by BJU International. Dr. Catalona is a signatory on the statement.

EAU Guidelines
-Early detection reduces prostate cancer deaths and the risk of being diagnosed with metastatic and advanced prostate cancer

-A baseline PSA should be obtained at 40-45 years of age
A baseline PSA above the median might be a better indicator of prostate cancer development than other risk factors, such as race and family history.

-Testing intervals should be adjusted according to the baseline PSA
Men with a PSA above 1.0 ug/l at 45–59 years of age should be screened every 2-4 years. Men with a PSA below this level could have a screening interval up to 8 years.

-PSA screening should be offered to men with a life expectancy of 10 or more years
A man’s life expectancy, rather than his age, should be considered when discussing prostate cancer screening or treatment.

-In the future, risk-prediction tools need to be part of the decision-making process
Multivariable risk-prediction tools such as risk calculators, clinical parameters such as new serum or urinary biomarkers, and the identification of specific genetic mutations associated with prostate cancer could help identify high-risk patients.

The guidelines were published by European Urology in June.

Dr. Catalona presented prostate cancer highlights at the Best of AUA Meeting in Tokyo, Japan. The AUA sends a delegation of its membership to summarize highlights from the annual AUA meeting to urologists in Japan.

Dr. Catalona explaining technical details about performing nerve-sparing radical prostatectomy to young urologists.

The URF Focus on Families
“I've discussed ‘value of survival’ with several men who have been diagnosed with prostate cancer. In our discussions I've asked them to write down their top 5 reasons to live. Grandchildren are usually at the top of the list.” –Michael F. Smiricky
Michael F. Smiricky’s grandchildren

Read the full article at http://epubs.democratprinting.com/article/EARLY+DETECTION+WORLDWIDE/1559286/183336/article.html.

A Forrwarrd--Lookiing Apprroach

William J. Catalona


By recommending that PSA testing should be abandoned completely or restricted, the USPSTF and the AUA guidelines are a step in the wrong direction for patient-centered care. If widely implemented, these guidelines would deprive many men of the opportunity to pursue shared decisionmaking about possibly life-saving PSA testing. A more forward-looking approach is needed. As stated by Dr. Harold Sox, “Weighing the pros and cons…is an individual process, and different well-informed men will make different decisions…guidelines should avoid recommending for or against PSA screening, rather we should recommend a shared decision process that includes assessing patients’ feelings about what they could go through after screening.”1

In the absence of shared decisionmaking, patients are more than twice as likely not to get tested. The future will bear out that PSA screening greatly reduces suffering and death from prostate cancer. The benefits far outweigh the harms.

Read the full article at http://epubs.democratprinting.com/article/A+Forrwarrd--Lookiing+Apprroach/1559287/183336/article.html.

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