PSA screening is a controversial issue as the RACGP guidelines do not recommend PSA screening. However, there is randomised evidence which demonstrates that PSA screening saves lives.
The American Urological Association, European Association of Urology and The Urological Society of Australia and New Zealand all recommend screening.
PSA screening should be discussed with all men 40 and over. They need to be counselled prior to ordering the test – they need to understand that screening may lead to MRI scans, prostate biopsies and the detection of cancers that may not require treatment.
More significant cancers can be found and treated and this is where lives are saved.
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 the median (~0.9 ng/mL) their lifetime risk of prostate cancer is low
What to do with an elevated PSA:
If the PSA is elevated it is reasonable to repeat it a month later. If it remains elevated this patient should be referred for further evaluation.
Aside from prostate cancer, elevated PSA can be caused by UTI, prostatitis, benign enlargement or prostatic stimulation.
I would suggest that:
- A single elevated PSA should be repeated to ensure that it is truly elevated
- Treat suspected prostatitis with a quinolone or Bactrim for 4-6 weeks and repeat the PSA
- Any man with a PSA that remains above the age specific range (usually provided by the lab) should be referred to a urologist for further evaluation
- Any man with a significantly rising PSA should be referred for evaluation
- When referring a patient, a copy of all prior PSA readings is helpful. Ultrasound is not necessary. If necessary I will arrange an MRI scan prior to biopsy (MRI attracts a Medicare rebate if ordered by a urologist)