From the Guidelines
A PSA increase from 1.7 to 5.24 warrants immediate referral to a urologist. This significant rise in Prostate Specific Antigen levels exceeds the normal rate of change, suggesting potential prostate cancer or other conditions like prostatitis or benign prostatic hyperplasia (BPH) 1. According to the Endocrine Society, a PSA increase of more than 1.5 ng/ml/yr or more than 0.75 ng/ml/yr over 2 years is concerning and may require a biopsy or urologic referral 1. In this case, the increase from 1.7 to 5.24 ng/ml is substantial and warrants further evaluation.
The urologist will likely perform additional testing, including a digital rectal examination, possibly repeat PSA testing, and may recommend a prostate biopsy to rule out prostate cancer 1. It is essential for the patient to avoid activities that might artificially raise PSA levels, such as ejaculation within 48 hours before testing, vigorous exercise involving the lower body, or bicycle riding. The patient should also inform the urologist about any medications they're taking, particularly 5-alpha reductase inhibitors like finasteride or dutasteride, which can affect PSA values 1. Prompt evaluation is crucial as earlier detection of any potential issues allows for more effective treatment options.
Key considerations for the urologist include:
- Performing a thorough medical history and physical examination
- Ordering additional tests, such as a prostate biopsy or imaging studies, if necessary
- Evaluating the patient's PSA velocity and doubling time to assess the risk of prostate cancer 1
- Discussing treatment options and recommendations with the patient, taking into account their individual needs and preferences.
By referring the patient to a urologist, we can ensure prompt evaluation and appropriate management of their condition, ultimately improving their outcomes and quality of life.
From the Research
PSA Increase and Referral to Urology
A PSA increase from 1.7 to 5.24 may indicate a need for further evaluation. According to 2, an elevated PSA level (greater than 4.0 ng./ml.) is a common criterion for performing quadrant biopsies.
Diagnostic Approaches
- Digital rectal examination (DRE) and transrectal ultrasonography have limited accuracy in identifying and localizing prostate cancer 2.
- The combined use of DRE and PSA testing provides a more complete evaluation of the prostate gland for malignant involvement 3.
- Advanced ultrasound modalities, such as multiparametric US (mp-US), can improve PCa diagnosis but are not sufficiently accurate to replace multiparametric MRI (mp-MRI) 4.
Referral to Urology
- Primary care physicians should understand the evaluation and management of common urologic disorders and know when to refer to a urologist 5.
- A significant increase in PSA level, such as from 1.7 to 5.24, may warrant referral to a urologist for further evaluation and potential biopsy 2, 3.
- The role of DRE in prostate cancer screening is limited, and its use is often supplementary to PSA testing 6.