Tag: AUA

The fact that Otis Brawley describes the new PSA testing guidelines of the American Urological Association (AUA) as “wonderful”, should immediately raise a red flag at AUA headquarters. Dr Brawley, Chief Medical Officer of the American Cancer Society, and the most vocal anti-prostate cancer screening voice in the USA over the past decade, has enthusiastically welcomed the new document and “commended” the AUA for bringing its policy closer to that of his Society. The Guidelines have also been compared to those of the United States Preventative Services Task Force (USPSTF) which completely opposes PSA testing in any situation – a position which the AUA called “inappropriate and irresponsible” just a few months ago. Oh dear – where has it all gone wrong? ?

For those who haven’t yet seen the document, here are the five statements issued by the Guideline committee at the Annual Meeting of the AUA in San Diego this week along with some of my thoughts in italics:

The Panel recommends against PSA screening in men under age 40 years. This appears reasonable.
The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk. I have some problems with this (as do many others). In addition to this statement, the AUA highlights its view that the likelihood of causing harm is high and that any benefit is marginal. It appears to have completely dismissed evidence (and its own previous view), that a baseline PSA in men in this age group is highly predictive of future prostate cancer, metastasis and death. In my view, there is considerable value in having a baseline PSA in this age group and I am disappointed that the AUA has not recognised the evidence to support this.
For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences. I agree with the emphasis here on shared decision-making, although the concept can be somewhat nebulous and difficult to achieve in real-life. However, I think that this statement somewhat over-emphasises the harms associated with PSA testing in this group. Rather than portray the reduction in prostate cancer mortality as being very minor (1 in 1000), men should know that when compared with a man who chooses not to have PSA testing in this age group, those who do have regular PSA testing have a 44% reduction in prostate-cancer mortality over a 14 year period. Furthermore, the numbers needed to screen (293) and number needed to treat (12) to save one life stack up very well when compared with other screening modalities such as mammography (Hugosson et al). Why has the AUA instead chosen to over-emphasise the harms? This is disappointing.
To reduce the harms of screening, a routine screening interval of two 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 two years preserve the majority of the benefits and reduce over-diagnosis and false positives. This appears reasonable.
The Panel does not recommend routine PSA screening in men over age 70 years or any man with less than a 10 to 15 year life expectancy. Yes, but this strong advice not to offer PSA testing in men greater than 70 belies the fact that many men in this age group have a long life expectancy (eg in Australia a male who reaches 70 has a 15 year life expectancy (www.abs.gov.au), and an early diagnosis of prostate cancer may prevent their untimely death from this disease. Clearly, not all men in their 70’s are the same but following this advice to the letter could deny many men the option of avoiding death from prostate cancer in later life.

Therefore, it appears that the only circumstances under which the AUA currently recommend a PSA test be performed is for men between the age of 55 and 69 following a weekend seminar so they can be adequately informed (or thoroughly confused).

These statements have led to headlines such as these in the mass media today:

Urology Group Stops Recommending Routine PSA Test (USA Today)
Looser Guidelines Issued on Prostate Cancer Screening (New York Times)
Urologists No Longer Support Routine Prostate Cancer Screening (Minn Post)
Most men don’t need PSA test (Arizona Star)
AUA No Longer Recommend Routine PSA Testing For Prostate Cancer (Huff Post)

I think it is reasonable to say that this AUA document adds more confusion than clarity to the debate around prostate cancer testing. It has certainly provoked some anger among prominent members of the AUA who voiced their displeasure to the Committee during the plenary and also through social media. Dr Catalona was first to the microphone asking why AUA members were not more widely consulted prior to publication and in particular, challenging the guidance around men aged 40-54 (reported on Twitter):

Dr Stacy Loeb also voiced her concerns at various sessions during the day:

Much progress has been made in the last few decades with a 30% reduction in prostate cancer-specific mortality since the introduction of PSA testing. And while we accept that this has led to a large amount of over-treatment of less aggressive disease, it is clear that (at least outside the USA), active surveillance is being enthusiastically embraced for appropriate patients. Any return towards the pre-PSA era would likely lead to a reversal in these mortality gains and we would again see many more men presenting to our rooms with incurable disease.

As Dr Smith editorialized in the Journal of Urology following the publication of the ERSPC and PLCO trials in 2009, “Treatment or non-treatment decisions can be made once a cancer is found, but not knowing about it in the first place surely burns bridges”. It is clear that many urologists consider these new AUA PSA Guidelines to be in danger of burning these bridges. However, rather than burn bridges, it is likely that urologists and others will ignore these guidelines and continue to counsel men in a more balanced fashion about the pros and cons of PSA testing. The AUA will then need to consider whether ignored guidelines are failed guidelines.

Prof Tony Costello is a Director and Professor of Urology at the Royal Melbourne Hospital, Melbourne, Australia.

Twitter: @proftcostello

Comments on this blog are now closed.

Greetings from San Diego, California! The annual meeting of the American Urological Association (AUA) is underway with over 15,000 attendees converging on this beautiful city from around the world. As I arrived at Pearson International Airport in Toronto on Friday and made my way through security I ran into roughly twenty of my colleagues from in and around Toronto getting ready to board the same plane. Canadians have attended this meeting in droves for as long as I can remember. Arriving in San Diego was easy with nice access to the city from the airport. After checking into hotel the first order of business was to register, which was also easy at least on Friday.

As I arrived on Friday it was clear that the meeting was already in full swing. A variety of research programs were underway including a Basic Science Symposium that explored the underlying role of inflammation and fibrosis in urological disorders.

Most noteworthy and newsworthy on Friday was the AUA news release of its new Guidelines on the Early Detection of Prostate Cancer. These will be sure to generate a lot of discussion. In summary:

Screening under age 40 is not recommended
Routine screening of men between age 40 and 54 at average risk is not recommended
For those aged 55-69, a shared decision to screen is advocated with a PSA drawn perhaps every two years.
Routine screening is not recommended after the age of 70.

These guidelines will be formally presented during Monday’s plenary session. The full document can be found here. It is clear to me that our challenge as urologists to properly council our patients in light of these new guidelines will only increase when you consider some of the headlines in the media. What do you think of these new Guidelines? Comments below please?

The first full day of scheduled activity was Saturday. A variety of sections and societies held meetings on this day. A number of courses were offered that continue to be well attended. This year a course pass was adopted that allowed individuals to get into most things available – a popular addition for AUA delegates. Highlights from the first day included:

The Engineering in Urology Section of the Endourology Society, highlighting advances in imaging as well as new robotic prototypes being developed from around the world. It will be interesting to see if any of these strange devices make it into the OR.
The Society of Urological Oncology was extremely well attended as usual. Dr Urs Studer delivered the Dr. W Whitmore Memorial Lecture and suggested that after more than 25 years in the PSA era a major re-think of how we treat prostate cancer is required.

Another very popular event was the live surgery session, which ran all day on Saturday. Highlights including a virtuoso robotic radical cystectomy with orthotopic ileal neobladder formation performed by Dr Indy Gill.

The role of robotic surgery to treat a variety of urological conditions is clearly expanding. For those of us in Canada the time is now to figure out how we will obtain, deploy, credential and manage this technology in our own publically funded healthcare system

The first plenary sessions began on Sunday. With the weather turning a little (I thought it never rains in Southern California?!) it made it easier to go indoors and listen to the talks and lectures inside. Highlight from plenary session one included a State-of-the Art Lecture of Technology’s role in the Future Management of Erectile Dysfunction by Dr Run Wang. Mention was made of nanotechnology and tissue engineering but perhaps the most intriguing near-term advance may be the advent of a smart phone app for operation of penile prostheses (yes it’s true!). Drs. Allen Seftel and Serge Carrier debated the role of the urologist in screening men with erectile dysfunction for cardiac disease. There was agreement on the link to cardiac disease but debate remains as to how many urologists will requisition stress tests. The second plenary session included an AUA Health policy update by Dr. David Penson and review by Dr. Peggy Pearle of the recertification process for urologists for the American Board of Urology.

As always, tremendous scientific efforts were on display at multiple poster and podium sessions. Predictably there was far too much for any one individual to entirely see. The discussion on Twitter via #AUA13 did allow for some ‘reporting’ at sites that I could not attend. A tremendous amount of work focusing on screening and active surveillance was clearly evident as well as the increasing use of new imaging techniques for managing these patients were evident. An afternoon session on HIFU and focal therapy left many people scratching their heads as to the utility of these modalities. The 47 % positive biopsy rate for HIFU was particularly disappointing. The best (or at least most entertaining) editorial of this session can be found in the twitter feed of @daviesbj.

In the science and technology exhibition area a tremendous presence from industry was again noted. Again, as a Canadian I am a little unsure as to how we will manage to incorporate all of this new technology when our hospital system is already strained. The Second Annual Residents Bowl narrowed down the field to two finalists, from the Western and South-eastern Sections. They will faceoff Monday at 1230 for the final. Finally the first Chief Residents’ debate highlighted that the future of our great speciality is very bright under the stewardship of these incredible young people.

For me a significant change to this meeting from past meetings is the use of social media to network, distribute ideas and scale down what often is a very large meeting into something that seems more accessible and local. The use of these multiple platforms has transformed the way we attend meetings. The recent meetings of the European Association of Urology (#eau13) and Urological Society of Australia and New Zealand (#USANZ13) highlight what can be achieved when this technology is used. Those not attending can participate actively. This has created an international participation in meetings in a way I have never seen before. The live twitter boards that you see around the convention centre here in San Diego, which are helping to spread the word, got their inspiration from these recent meetings.

A few individuals such as @daviesb and @DrHWoo and @tdave deserve credit for insisting that these boards become of feature of the 2013 meeting. Well done to AUA for taking a proactive approach to social media this year and for listening to your members. The hashtag to follow is #AUA13. I would encourage all to participate in this community. You will be amazed at how easily you can find out about what’s really going on at this meeting and also check in at venues that you cannot otherwise physically attend. You can see who are the leading influencers on twitter at #aua13 by checking out updated metrics via Symplur. You can see from this link that the chatter is building daily. I look forward to seeing a similar picture at #CUA13 when the Canadian Urological Association meets in June.

The use of Social Media will rapidly increase in scope and become a necessary part of communication within our Urological meetings. The AUA (@Americanurol) has recently established a committee to establish guidelines help grow its use for AUA members. Sign up for an account and dive in. It is highly engaging, somewhat addictive, very informative and always fun!

The BJUI hosted a great event, The BJUI Social Media Awards, for all of the early adopters of social media on Saturday evening. In particular this group has networked and communicated regularly over the last six months and ‘meet’ once a month to run a journal club on twitter using the hashtag #urojc. They self-identify as urotwitterati. The BJUI
arranged for many of us to meet for the first time by hosting the #BJUISoMeAwards. It was a great event and will be fully featured in a separate blog this week along with details of the well-attended BAUS/BJUI Session that took place on Sunday afternoon and included the awarding of the Coffey-Krane Prize.

Lastly on Sunday, by the security guards in Sacramento CA, we were treated to a spectacular Reception on board the USS Midway, a first opportunity for most of us to go on board a gigantic aircraft carrier and see some wonderful aircraft. The flight simulators were only for those who had not had a few beers already and who could tolerate the high G forces! Well done again to AUA for this excellent event.

Monday’s plenary session will include some very interesting debate around nephrolithiasis and I look forward to a Town Hall led by Dr. Ralph Clayman debating Robots as a possible harbinger of Surgeon Obsolescence. New guidelines on castration resistant prostate cancer will also be presented. Stay tuned for further updates from @Matthayn on Wednesday

Posts

The new AUA PSA Testing Guidelines leave me scratching my head

AUA Blog – Highlight of Day 1 and 2

Read Day 3 & 4 Highlights here

Tag Archive for: AUA

Posts

Read Day 3 & 4 Highlights here