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Andrew J. Vickers

Firm evidence shows that prostate-specific antigen (PSA) velocity is statistically associated with many prostate cancer outcomes, including those related to early detection. However, the clinical use of a marker depends on clinical and statistical significance. Before PSA velocity is used to inform decisions such as whether to perform a biopsy, evidence should be clear that doing so would improve clinical outcome. A systematic review on PSA velocity found that almost no studies had evaluated whether PSA velocity aids in clinical decision-making. Since that time, several reports have indicated that including PSA in a statistical model alongside standard predictors (eg, PSA, digital rectal examination) does not improve predictive accuracy. Specifically, performing a biopsy on men with high PSA velocity in the absence of other indications, as recommended by the NCCN Clinical Practice Guidelines in Oncology for Prostate Cancer Early Detection, would lead to many millions of unnecessary biopsies, without a corresponding number of aggressive cancers being detected. Advocates of PSA velocity have been reduced to citing a single article claiming that PSA velocity aids in clinical decision-making. The article involves selective reporting of an unusual subgroup analysis based on an extremely limited number of events. This is not to say that, in clinical practice, urologists should ignore prior PSA values: clinical judgment can be aided by careful longitudinal evaluation of PSA changes, interpreted in the context of symptoms and treatments. However, the literature clearly shows that simplistic application of PSA velocity cutoffs is not of value for early detection of prostate cancer.

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Peter R. Carroll and Andrew J. Vickers

Few clinical issues have polarized the oncology community as much as screening for prostate cancer, with advocates of prostate-specific antigen (PSA) testing vocal on one side and skeptics just as vocal on the other. At the NCCN 19th Annual Conference, Dr. Peter R. Carroll and Dr. Andrew J. Vickers tackled the controversy surrounding early detection of prostate cancer, focusing attention on the randomized trial results at the heart of the matter; over-detection (the Achilles’ heel of screening); and the rationale behind the new, streamlined 2014 NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Prostate Cancer Early Detection, which emphasize selective early detection and treatment and are tightly aligned with the NCCN Guidelines for Prostate Cancer.

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Armin Shahrokni, Amy Tin, Robert J. Downey, Vivian Strong, Sanam Mahmoudzadeh, Manpreet K. Boparai, Sincere McMillan, Andrew Vickers and Beatriz Korc-Grodzicki

Background: The American College of Surgeons and American Geriatrics Society recommend performing a geriatric assessment (GA) in the preoperative evaluation of older patients. To address this, we developed an electronic GA, the Electronic Rapid Fitness Assessment (eRFA). We reviewed the feasibility and clinical utility of the eRFA in the preoperative evaluation of geriatric patients. Methods: We performed a retrospective review of our experience using the eRFA in the preoperative assessment of geriatric patients. The rate and time to completion of the eRFA were recorded. The first 50 patients who completed the assessment were asked additional questions to assess their satisfaction. Descriptive statistics of patient-reported geriatric-related data were used for analysis. Results: In 2015, 636 older patients with cancer (median age, 80 years) completed the eRFA during preoperative evaluation. The median time to completion was 11 minutes (95% CI, 11–12 minutes). Only 13% of patients needed someone else to complete the assessment for them. Of the first 50 patients, 88% (95% CI, 75%–95%) responded that answering questions using the eRFA was easy. Geriatric syndromes were commonly identified through the performance of the GA: 16% of patients had a positive screening for cognitive impairment, 22% (95% CI, 19%–26%) needed a cane to ambulate, and 26% (95% CI, 23%–30%) had fallen at least once during the previous year. Conclusions: Implementation of the eRFA was feasible. The eRFA identified relevant geriatric syndromes in the preoperative setting that, if addressed, could lead to improved outcomes.

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Peter R. Carroll, J. Kellogg Parsons, Gerald Andriole, Robert R. Bahnson, Daniel A. Barocas, Erik P. Castle, William J. Catalona, Douglas M. Dahl, John W. Davis, Jonathan I. Epstein, Ruth B. Etzioni, Thomas Farrington, George P. Hemstreet III, Mark H. Kawachi, Paul H. Lange, Kevin R. Loughlin, William Lowrance, Paul Maroni, James Mohler, Todd M. Morgan, Robert B. Nadler, Michael Poch, Chuck Scales, Terrence M. Shaneyfelt, Marc C. Smaldone, Geoffrey Sonn, Preston Sprenke, Andrew J. Vickers, Robert Wake, Dorothy A. Shead and Deborah Freedman-Cass

Prostate cancer represents a spectrum of disease that ranges from nonaggressive, slow-growing disease that may not require treatment to aggressive, fast-growing disease that does. The NCCN Guidelines for Prostate Cancer Early Detection provide a set of sequential recommendations detailing a screening and evaluation strategy for maximizing the detection of prostate cancer that is potentially curable and that, if left undetected, represents a risk to the patient. The guidelines were developed for healthy men who have elected to participate in the early detection of prostate cancer, and they focus on minimizing unnecessary procedures and limiting the detection of indolent disease.

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Peter R. Carroll, J. Kellogg Parsons, Gerald Andriole, Robert R. Bahnson, Erik P. Castle, William J. Catalona, Douglas M. Dahl, John W. Davis, Jonathan I. Epstein, Ruth B. Etzioni, Thomas Farrington, George P. Hemstreet III, Mark H. Kawachi, Simon Kim, Paul H. Lange, Kevin R. Loughlin, William Lowrance, Paul Maroni, James Mohler, Todd M. Morgan, Kelvin A. Moses, Robert B. Nadler, Michael Poch, Chuck Scales, Terrence M. Shaneyfelt, Marc C. Smaldone, Geoffrey Sonn, Preston Sprenkle, Andrew J. Vickers, Robert Wake, Dorothy A. Shead and Deborah A. Freedman-Cass

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Prostate Cancer Early Detection provide recommendations for prostate cancer screening in healthy men who have elected to participate in an early detection program. The NCCN Guidelines focus on minimizing unnecessary procedures and limiting the detection of indolent disease. These NCCN Guidelines Insights summarize the NCCN Prostate Cancer Early Detection Panel's most significant discussions for the 2016 guideline update, which included issues surrounding screening in high-risk populations (ie, African Americans, BRCA1/2 mutation carriers), approaches to refine patient selection for initial and repeat biopsies, and approaches to improve biopsy specificity.

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Peter R. Carroll, J. Kellogg Parsons, Gerald Andriole, Robert R. Bahnson, Daniel A. Barocas, William J. Catalona, Douglas M. Dahl, John W. Davis, Jonathan I. Epstein, Ruth B. Etzioni, Veda N. Giri, George P. Hemstreet III, Mark H. Kawachi, Paul H. Lange, Kevin R. Loughlin, William Lowrance, Paul Maroni, James Mohler, Todd M. Morgan, Robert B. Nadler, Michael Poch, Chuck Scales, Terrence M. Shanefelt, Andrew J. Vickers, Robert Wake, Dorothy A. Shead and Maria Ho

The NCCN Guidelines for Prostate Cancer Early Detection provide recommendations for men choosing to participate in an early detection program for prostate cancer. These NCCN Guidelines Insights highlight notable recent updates. Overall, the 2014 update represents a more streamlined and concise set of recommendations. The panel stratified the age ranges at which initiating testing for prostate cancer should be considered. Indications for biopsy include both a cutpoint and the use of multiple risk variables in combination. In addition to other biomarkers of specificity, the Prostate Health Index has been included to aid biopsy decisions in certain men, given recent FDA approvals.