Tuesday, August 5, 2014

What to do with abnormal PSA results in a young man?

A 45-year-old man in excellent health with no family history of prostate cancer had a screening PSA done three years ago which was in the range of 4.0 ng/mL. He has been followed by a urologist, and the test was repeated several times without much change.

In June of this year, his PSA was 4.6 and the free PSA was 0.6 for a ratio of 0.13. He was given a course of antibiotics for presumed prostatitis, and repeat testing a month later showed a PSA of 3.8 with a free PSA of 0.5. Because the PSA was less than 4, a ratio was not calculated.

The patient obtained copies of the reports. The from June one states the following: "When total PSA is in the range of 4.0-10.0 ng/mL, a free PSA/total PSA ratio of less than or equal to 0.10 indicates a 49% to 65% risk of prostate cancer depending on age. A free PSA/total PSA ratio of greater than 0.25 indicates a 9% to 16% risk of prostate cancer depending on age." It does not comment on the significance of a ratio of 0.13, which I have looked up. The cancer risk is in the area of 20%-25%. However, no source gave estimates for men under the age of 50.

On examination, his urologist can feel no nodules. He has recommended that the patient undergo an MRI of the prostate.

Stating that an MRI is not indicated in a man of his age with his history, the patient's insurance company will not pay for the test and suggested a trans-rectal ultrasound. The urologist advised the patient not to have an ultrasound due to his age and the potential for complications. A hospital quoted him an out-of-pocket price of $2500 for the MRI.

The urologist has told him that random biopsies may not be accurate and there is a risk of complications.

When he had his first PSA done three years ago, I had expressed surprise and wondered why it had been offered to him. The patient said his internist told him he should have the test.

He is concerned about these recent results and has asked me for advice which I am not qualified to give.

What would you advise?

Follow-up August 6, 2014

Numerous urologists responded on Twitter with more than 60 tweets about this post. Suggestions for the next step were as follows: trans-rectal ultrasound (TRUS) and biopsy as mentioned by Dr. Cooperberg below; going ahead with the MRI; repeating the PSA in 3 months; go for a second opinion by a recognized expert in prostate cancer.

One urologist emailed me to point out that even if the patient has cancer, it is probably not an aggressive type because his PSA has not risen in 3 years.

Another urologist gave me the name of an expert in the patient's geographic area. 

The patient has already scheduled an appointment for a second opinion.

4 comments:

Melissa B said...

Perhaps refer him to the web site for the US Preventative Services Task Force at http://www.uspreventiveservicestaskforce.org/prostatecancerscreening.htm

Matthew Cooperberg, MD,MPH said...

Definitely do NOT refer to USPSTF website if you want him to actually learn about the pros and cons of PSA testing and prostate cancer early detection. Their statement grossly misinterprets key trials and egregiously cherry picks the literature. There is a strong rationale for earlier, less frequent testing for healthy men, and many would argue for a baseline at 40 to 45.

All that aside, if a 45 year old man has a confirmed PSA anywhere near 4, that is much too high for his age and if he's in good health he should undergo TRUS (ultrasound)-guided biopsy to rule out the presence of high-grade prostate cancer.

There is no established role for MRI before a first biopsy.

And incidentally, empiric treatment with antibiotics for asymptomatic men with elevated PSA is typically fruitless and is discouraged by the AUA's Choosing Wisely campaign.

So the bottom line is: standard of care = TRUS-guided biopsy, and appropriate treatment if high-risk disease is identified (active surveillance for low-risk disease).

Skeptical Scalpel said...

Melissa and Matt, thanks for commenting. I'm afraid it's too large for the USPSTF. He's had the PSA and now something must be done.

Matt, what if there is no specific lesion to biopsy on the TRUS and all the samples come back negative?

Skeptical Scalpel said...

My previous comment should have read "it's too late for the USPSTF." I will blame autocorrect.

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