What is the clinical significance of a 65-year-old male's elevated Prostate-Specific Antigen (PSA) level of 5.0, with a history of high-grade bladder Transitional Cell Carcinoma (TCC), Benign Prostatic Hyperplasia (BPH), and recent Computed Tomography (CT) scan showing prostatomegaly with bladder outlet obstruction?

From the Guidelines

The patient should continue the current combination pharmacotherapy with Flomax and Proscar for BPH management, and follow up in three months for surveillance cystoscopy, urine FISH cytology, and repeat PSA testing, as this approach balances ongoing management of his BPH symptoms while maintaining appropriate cancer surveillance given his history of bladder cancer. The patient's history of high-grade bladder transitional cell carcinoma (TCC) diagnosed 7 years ago, and recent atypical cells on urine cytology in January 2025, warrant continued surveillance 1. The recent cystoscopies in January and April 2025 showed an obstructing prostate, trabeculated bladder, but normal bladder mucosa with no evidence of cancer recurrence, which supports the continuation of the current treatment plan. The patient's most recent PSA is 5.0 ng/mL with normal kidney function (creatinine 0.9), which is within the expected range for a patient with BPH, and the CT scan revealed prostatomegaly causing bladder outlet obstruction, but no suspicious masses or malignancy 1.

The benefits and risks of PSA testing should be discussed with the patient, and the patient should be informed that a normal DRE should be sufficient to exclude locally advanced cancer as a cause of voiding dysfunction, but PSA testing is most appropriate for patients likely to have a natural life span greater than 10 years and in whom the known presence of prostate cancer would change management or for whom the PSA measurement may change the management of the patient’s voiding symptoms 1.

The patient's history of smoking and other risk factors for bladder cancer also support the continued surveillance, and the patient should be encouraged to continue with the recommended follow-up appointments to monitor his condition. Additionally, the patient should see a gastroenterologist for evaluation of possible enteritis noted on his CT scan.

Some key points to consider in the patient's management plan include:

• Continued combination pharmacotherapy with Flomax and Proscar for BPH management
• Follow-up in three months for surveillance cystoscopy, urine FISH cytology, and repeat PSA testing
• Continued surveillance for bladder cancer given the patient's history and recent atypical cells on urine cytology
• Evaluation of possible enteritis by a gastroenterologist
• Discussion of the benefits and risks of PSA testing with the patient.

From the FDA Drug Label

1. 1 Effects on Prostate Specific Antigen (PSA) and the Use of PSA in Prostate Cancer Detection

In clinical studies, finasteride tablets reduced serum PSA concentration by approximately 50% within six months of treatment. This decrease is predictable over the entire range of PSA values in patients with symptomatic BPH, although it may vary in individuals For interpretation of serial PSAs in men taking finasteride tablets, a new PSA baseline should be established at least six months after starting treatment and PSA monitored periodically thereafter Any confirmed increase from the lowest PSA value while on finasteride tablets may signal the presence of prostate cancer and should be evaluated, even if PSA levels are still within the normal range for men not taking a 5α-reductase inhibitor.

The patient's most recent PSA is 5.0. To interpret this value, it should be doubled for comparison with normal ranges in untreated men, as the patient has been taking finasteride for more than six months. Therefore, the adjusted PSA value would be 10.0. This adjustment preserves the utility of PSA to detect prostate cancer in men treated with finasteride tablets 2.

From the Research

Patient's Condition

The patient is a 65-year-old male with a history of elevated PSA and high-grade bladder cancer diagnosed 7 years ago. He has undergone multiple cystoscopies and transurethral resection of the bladder tumor. The patient is currently experiencing occasional nocturia and is being treated with Flomax and Proscar.

Treatment Options

• The patient's treatment options for benign prostatic hyperplasia (BPH) include medical therapy, minimally invasive procedures, and surgical interventions 3.
• Tamsulosin, an alpha-adrenergic receptor antagonist, has been shown to improve symptoms and peak urine flow in patients with BPH 4, 5, 6.
• Finasteride, a 5-alpha reductase inhibitor, has been shown to improve long-term urinary symptoms and reduce the risk of BPH progression 7.

Medications

• The patient is currently taking finasteride (Proscar) and tamsulosin (Flomax), which are commonly used to treat BPH.
• Tamsulosin has been shown to be effective in improving symptoms and peak urine flow, with a low risk of adverse effects 4, 5, 6.
• Finasteride has been shown to improve long-term urinary symptoms and reduce the risk of BPH progression, but may be associated with an increased risk of ejaculation disorder, impotence, and lowered libido 7.

Monitoring and Follow-up

• The patient's PSA level is being monitored, with a recent level of 5.0.
• The patient is scheduled for follow-up cystoscopy and urine FISH cytology in 3 months.
• The patient's treatment plan will be re-evaluated based on the results of these tests and any changes in his symptoms.

Key Points

• The patient's BPH is being managed with a combination of medical therapy (finasteride and tamsulosin) and monitoring.
• The patient's PSA level and urinary symptoms will be closely monitored to assess the effectiveness of treatment and detect any potential complications.
• The patient's treatment plan may be adjusted based on the results of follow-up tests and any changes in his symptoms.