AUA PCa Treatment Guidelines

From the AUA report, the section about PSAV. I agree that It is one of the tools that a doctor uses for determination of the need for a biopsy but the literature is not definitive and whatever we say we need to be balanced.

PSAV is primarily used to detect prostate

cancer, whereas PSADT is primarily used in the post treatment setting as a surrogate marker of

outcome. Some investigators have suggested that a PSA rise of 0.75 ng/mL or greater in a year is

reason for concern in patients with a PSA level >4.0 ng/mL (Carter 1992). While a PSAV of

0.75 ng/ml per year has been recommended for men with PSA values between 4-10 ng/ml,

several studies suggest that lower PSAV thresholds of 0.4 ng/ml per year may improve prostate

cancer detection for younger men and for those with PSA levels below 4.0 ng/ml (Moul 2007,

Loeb 2007, D’Amico 2004, Carter 2006). To correctly measure PSAV, use of at least three PSA

values over a time period of at least 18 months is recommended (Carter 2006, D’Amico 2004).

Estimating PSAV with values spread over a longer interval is problematic because when

significant prostate cancer is present, PSA increases exponentially and a linear estimate of PSA

slope is less valid. The problem of using linear regression to estimate the slope of an

exponentially rising PSA can be easily overcome by calculating an average PSAV between 3

measures (the annualized PSAV between the first 2 measures plus the annualized PSAV between

the second 2 measures divided by 2). Some have suggested that PSAV cutpoints should be

lowered and age adjusted. Age-adjusted PSA velocities with threshold values of 0.25 ng/mL/yr

in men ages 40 to 59, 0.5 ng/mL/year in men ages 60 to 69, and 0.75 ng/mL/year for men over

70 years of age have been proposed (Moul 2007). Both age-specific PSA and age-specific PSAV

will increase the number of cancers detected, and both will also increase the number of younger

men undergoing biopsy. However, when added to total PSA, PSAV was not shown to be a useful

independent predictor of positive biopsy, , in the ERSPC and PCPT trials, or in other

analyses(Etzioni 2007, Wolters 2008, Vickers 2009).

As you said one of our objectives is to teach men that not all prostate cancers will cause their deaths and that for selected men AS is a good alternative.

The problem with many men is that the fear of death causes them to rush to treatment. We want them, unless they have an advanced cancer to slow down and become empowered to make good and personal treatment choices. We want to teach them how to effectively discuss the issues with their doctors. We can’t tell them what to do because each choice is very individualized. Part of that is to let them know that not all prostate cancer is clinically aggressive.

We also need to change the perception by society that all cancers will kill you without making it appear that no cancers will kill you. Not easy.

The word screening just means present/not present. Early detection of clinically significant prostate cancer helps to educate men that not all men will die from prostate cancer and at the same time focuses on the need that men have to know which cancer is aggressive and which is not.

Changing wording can be difficult at first but if all groups begin using the phrase it will become standard. The national groups have accepted the change and it’s is being discussed at both the ASCO and AUA meetings.

Kathy