From the Guidelines
The next step in managing a 94-year-old patient with rising PSA from 4.35 to 6.44 should be no further diagnostic testing or treatment, as the potential harms of aggressive diagnosis and treatment may outweigh the benefits, given the patient's advanced age and the slow progression of prostate cancer 1. The patient's age and rising PSA level should be considered in the context of their overall health status and life expectancy.
- The risk of dying from causes other than prostate cancer is significantly higher at 94 years old, and the potential harms of aggressive diagnosis and treatment (including biopsy complications, treatment side effects) may outweigh the benefits, as prostate cancer often progresses slowly and may never become clinically significant during the patient's remaining lifetime.
- The American College of Physicians recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in men over the age of 69 years, or men with a life expectancy of less than 10 to 15 years 1.
- A conservative approach, focusing on watchful waiting or active surveillance, may be the most appropriate course of action, as it avoids the potential harms of aggressive treatment and allows the patient to maintain their quality of life.
- Regular monitoring of the patient's symptoms and overall health status is still necessary, but further diagnostic testing or treatment should only be considered if the patient develops urinary symptoms or other significant health issues. Given the patient's advanced age and the slow progression of prostate cancer, a conservative approach, focusing on watchful waiting or active surveillance, is the most appropriate course of action, as it prioritizes the patient's quality of life and avoids the potential harms of aggressive treatment 1.
From the Research
Prostate-Specific Antigen (PSA) Level Concerns
- A PSA level of 6.44 for a 94-year-old patient, with a previous level of 4.35 in 2024, may be concerning and warrants further evaluation 2.
- The increase in PSA level from 4.35 to 6.44 may indicate a higher risk of developing prostate cancer, as studies have shown that fluctuations in PSA levels can be associated with an increased risk of prostate cancer development 2.
Next Steps in Management
- Referral to a urologist can be considered for patients with a rising prostate-specific antigen (PSA), especially if the patient is experiencing symptoms or if the PSA level is increasing rapidly 3.
- A digital rectal examination (DRE) may be performed as part of the evaluation, although its diagnostic value as a screening test for prostate cancer has been questioned in recent studies 4, 5.
- Further testing, such as a biopsy or imaging studies, may be necessary to determine the cause of the elevated PSA level and to rule out prostate cancer 6, 2.
Considerations for Older Adults
- The management of elevated PSA levels in older adults, such as the 94-year-old patient in question, requires careful consideration of the patient's overall health, life expectancy, and potential risks and benefits of further testing and treatment 3, 2.
- The patient's symptoms, medical history, and preferences should be taken into account when determining the best course of action 3, 4.