From the Guidelines
An increase in PSA from 1.6 to 3.0 over two years for a 76-year-old male is potentially concerning and warrants follow-up evaluation, considering the patient's age and the natural increase in PSA levels with age 1.
Key Considerations
- The velocity of PSA increase is approximately 0.7 ng/mL per year, which exceeds the threshold of concern (typically 0.75 ng/mL per year for men with PSA levels under 4.0) 1.
- The evaluation may include a digital rectal examination, possibly a free PSA test to determine the ratio of free to total PSA, and consideration of prostate imaging such as an MRI or a prostate biopsy depending on other risk factors 1.
- PSA can also rise due to non-cancerous conditions like benign prostatic hyperplasia (BPH), prostatitis, or recent ejaculation.
- For a 76-year-old, life expectancy and overall health status should be considered when determining how aggressively to pursue diagnosis and potential treatment, as some prostate cancers at this age may be slow-growing and might not impact life expectancy 1.
Next Steps
- Discuss the potential benefits and harms of prostate cancer screening and treatment with the patient, considering their personal preferences and health status 1.
- Consider a cut point of >4 ng/mL for biopsy in men over 75 years old, as suggested by the NCCN guidelines 1.
- Evaluate the patient's overall health and life expectancy to determine the best course of action for diagnosis and potential treatment.
From the FDA Drug Label
In clinical studies, finasteride tablets reduced serum PSA concentration by approximately 50% within six months of treatment. 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. Men aged 55 and over with a normal digital rectal examination and PSA ≤3.0 ng/mL at baseline taking finasteride 5 mg/day in the 7-year Prostate Cancer Prevention Trial (PCPT) had an increased risk of Gleason score 8 to 10 prostate cancer (finasteride 1.8% vs placebo 1.1%).
The increase in PSA from 1.6 to 3.0 over 2 years in a 76-year-old male may be significant and should be evaluated further. Next steps may include:
- Repeating the PSA test to confirm the increase
- Performing a digital rectal examination
- Considering a biopsy to rule out prostate cancer
- Evaluating the patient's overall health and medical history to determine the best course of action 2
From the Research
Prostate-Specific Antigen (PSA) Increase Significance
- A PSA increase from 1.6 to 3.0 over 2 years in a 76-year-old male may be considered significant, as it exceeds the expected annual increase in PSA levels 3.
- According to a study published in 2015, the age-adjusted PSA cut-off value for men aged 70 years or older is 3.25 ng/mL 4.
- In this case, the patient's PSA level has reached 3.0 ng/mL, which is close to the age-adjusted cut-off value.
Next Steps
- Further evaluation, such as a digital rectal examination (DRE) and/or magnetic resonance imaging (MRI), may be necessary to determine the cause of the PSA increase 5, 6.
- A biopsy may be considered if the DRE is suspicious or if the MRI shows abnormalities, even if the PSA level is not significantly elevated 7.
- It is essential to consult with a healthcare professional to determine the best course of action, as individual circumstances and medical history can influence the decision-making process.
Diagnostic Considerations
- DRE may still have a role in the prostate cancer diagnostic pathway, particularly in patients with elevated PSA levels 5, 7.
- However, the use of MRI and PSA measurements has become more prevalent in recent years, especially during the COVID-19 pandemic 6.
- Age-adjusted PSA reference values and PSA density (PSAD) may also be considered in the diagnostic process to increase the positive predictive value (PPV) of PSA testing 3.