AUA 2017: How I Screen - Panel

Boston, MA ( This was a comprehensive discussion from world-wide thought leaders regarding their approaches to prostate cancer screening. This is particularly timely given the immense movement in the field with regards to changing guidelines for PSA-based screrening, implementation of MRI, and adjunctive PSA-based and urinary based tests like free PSA, 4Kscore, PHI, and confirmDx. The obvious goal is to increase the sensitivity and specificity of prostate cancer screening to minimize negative biopsies with their inherent risks, and maximize detection of clinically significant but still curable prostate cancer. The four panelists reviewed the guidelines from their respective organizations regarding prostate cancer screening.

EAU view: Nicolas Mottet, MD-PhD. Based on the most recent ERSPC data, in order to save one life due to prostate cancer over 13 yrs 781 men would be needed to screen, and 27 needed to treat (NNT). Even though their study was positive (as opposed to PLCO), PSA based screening still resulted in overdiagnosis and overtreatment. The recently published EAU guidelines were based on these data. In these guidelines, routine screening was not recommended, but Dr. Mottet thinks this may change if longer follow up continues to drop the NNT. But the EAU does provide a grade A recommendation for a risk-adapted strategy with input from patient. Risk factors included men >50, men >45 with FH, AA >45, PSA >1 at 40, or PSA >2 at 60. The EAU does not recommend genetic testing yet. In men with risk factors, and PSA 2-10, they recommend using a risk calculator, or additional serum or urine based tests. For testing interval, the EAU recommends PSA every 2 years in at risk men and delaying up to 8 yrs in men with no risk factors. They recommend screening only if life expectancy exceeds 15 yrs. He concluded by underscoring the concept that divorcing diagnosis and treatment through active surveillance is critical, although the EAU guidelines for AS were not discussed here.

NCCN view: J. Kellogg Parsons, MD, MHS. In 5 minutes, Dr. Parsons discussed 3 algorithms that are published in the NCCN guidelines: 1) whether to screen. 2) Interpretation of PSA results and whether to biopsy. 3) Interpretation of biopsy results and whether to treat.
In men between age 45-75 with a PSA >3, the NCCN recommends biopsy or adjunctive tests. If there is no cancer detected on biopsy, the NCCN recommends MRI or reflex testing.
In 2017, the NCCN will update its recommendations to include: in patients >75 yrs, PSA threshold increased to >4. They will make recommendations on family history and genetic testing. They will discuss new biomarkers. They will likely recommend consideration of upfront mpMRI (prior to biopsy).

AUA view: Herbert B. Carter, MD. Johns Hopkins University. Dr. Carter presented 1 slide summarizing the AUA guidelines. He emphasized the importance of individualized decision making. He stated that biennial testing may reduce harms of PSA testing. The target group is age 55-69yrs with caveats for FH, race, and healthy older men.
Asia view: Kazuto Ito, MD. Gunma University. Dr. Ito presented 1 slide. He reminded us of the relatively low incidence of PCa in Asian countries, but pointed out that the incidence is greatly increasing. The reasons for this (increased screening/testing?) was not elaborated. He recommends to check baseline PSA in late 40s or early 50s and follows age-specific PSA thresholds for biopsy. Age<65y: 3.0ng/ml. Age 65-69: 3.5, Age>70: 4. He recommends rescreening at differing intervals dependent on PSA levels: Every year if PSA >1.1, every 3 years if PSA <1. He recommends to stop screening based on G8 geriatric tool especially for men >80yrs.

Overall, the four presenters had very thoughtful and similar approaches, which should reassure our patients.

Presented by: Nicolas Mottet, MD-PhD University Hospital north and J. Kellogg Parsons, MD, MHS UC San Diego Moores Cancer Center

Contributed by: Jed Ferguson, MD/PhD and Ashish Kamat, MD. MD Anderson Cancer Center, Department of Urology.

at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA