Is a Transrectal Ultrasound (TRUS) indicated for a 76-year-old patient with recently elevated Prostate-Specific Antigen (PSA) and a normal Digital Rectal Examination (DRE)?

From the Guidelines

It does not make sense to perform a transrectal ultrasound (TRUS) for a 76-year-old patient with recently elevated PSA and normal digital rectal examination (DRE) due to the potential harms outweighing the benefits in this age group. According to the guidance statement from the American College of Physicians 1, screening for prostate cancer using the prostate-specific antigen (PSA) test is not recommended in men over the age of 69 years or those with a life expectancy of less than 10 to 15 years, as the harms associated with screening and treatment are substantial and the benefits are questionable.

Key points to consider in this scenario include:

• The patient's age and potential life expectancy, which influence the likelihood of prostate cancer causing morbidity or mortality within their remaining lifespan.
• The fact that elevated PSA levels can be due to benign conditions, and the risk of false-positive results leading to unnecessary biopsies and treatments.
• The potential harms of prostate cancer screening and treatment, including overdiagnosis, overtreatment, and the side effects of treatments such as surgery and radiation therapy, as highlighted in the guidance statement 1.
• The importance of shared decision-making, where the patient's preferences, values, and understanding of the benefits and harms are taken into account before proceeding with any diagnostic or therapeutic interventions.

Given these considerations and the evidence from the American College of Physicians guidance statement 1, the focus should be on managing the patient's overall health and addressing any symptoms or concerns they may have, rather than pursuing further diagnostic testing for prostate cancer at this stage.

From the Research

TRUS for a 76-year-old patient with elevated PSA and normal DRE

• The decision to perform a Transrectal Ultrasound (TRUS) on a 76-year-old patient with recently elevated Prostate-Specific Antigen (PSA) and normal Digital Rectal Examination (DRE) should be based on various factors, including the patient's age, PSA level, and overall health condition.
• According to the study by 2, the use of age-specific PSA ranges can increase the sensitivity of PSA testing in younger men and decrease the biopsy rate in older patients who may not be candidates for aggressive treatment.
• The same study found that 22% of patients over the age of 70 would be spared TRUS with biopsy if age-adjusted PSA were used.
• Another study by 3 suggests that repeating a PSA test in patients with an elevated PSA level can decrease the risk of prostate biopsy and cancer diagnosis.
• However, the studies by 4, 5, and 6 focus on the use of 5-alpha-reductase inhibitors for prostate cancer prevention and do not directly address the question of whether to perform TRUS on a 76-year-old patient with elevated PSA and normal DRE.

Considerations for TRUS in older patients

• The patient's age and overall health condition should be taken into account when deciding whether to perform TRUS.
• The potential benefits of TRUS, such as detecting prostate cancer, should be weighed against the potential risks and discomfort associated with the procedure.
• Alternative approaches, such as repeating the PSA test or using age-adjusted PSA ranges, may be considered before proceeding with TRUS.
• The studies by 2 and 3 suggest that a more nuanced approach to PSA testing and biopsy may be warranted in older patients, taking into account their age, PSA level, and overall health condition.