PSA screening is a controversial issue. RACGP guidelines do not recommend PSA screening. The US preventative services task force have also suggested that screening shuld not be performed.
The American Urological Association, European Association of Urology and The Urological Society of Australia and New Zealand all recommend screening. I believe that men should be given the option of being screened and they must be counseled prior to ordering a PSA.
This would involve telling them that the PSA test is not perfect and that it may raise many questions. It may also lead to prostate biopsies as well as treatment which may make them live longer but which may also impact on their quality of life, especially sexual function.
PSA screening guidelines:
- Men with family history (first degree relatives) should be screened from age 40 with digital rectal exam and PSA annually
- Men without family history should be screened with annual DRE and PSA from age 50
- Men can have a single PSA at age 40 to quantitate their cancer risk. If the single PSA is less than one their risk is low
What to do with an elevated PSA:
There may be a degree of biological variation in PSA and aside from prostate cancer there can be multiple reasons for elevated PSA. These include urinary tract infection, prostatitis, enlarged prostates or prostatic stimulation/ejacuation prior to the PSA being drawn.
I would suggest that:
- A single elevated PSA should be repeated to ensure that it is truly elevated. If there are any associated lower urinary tract symptoms antibiotics like Bactrim can be tried and the PSA repeated in two weeks.
- Treat suspected prostatitis with a quinolone or Bactrim for 4-6 weeks and repeat the PSA
- Any man with a PSA above the age specific range (usually provided by the lab) should be referred to a urologist for further evaluation
- Any man with a rising PSA should be referred for evaluation. Indication for biopsy would be a PSA rising by over 0.35ng/mL per year or abnormal rectal examination.
- Generally no radiological investigations are required when referring a patient for elevated or rising PSA. A copy of all PSA values would be helpful.
- If prostate cancer is found then staging generally consists of abdominal CT as well as bone scan.