What is the next step for a patient with elevated Prostate-Specific Antigen (PSA)?

From the Guidelines

The next step for a patient with elevated PSA is typically a referral to a urologist for further evaluation, where a digital rectal examination (DRE) and additional PSA testing may be performed to confirm the elevation, and if necessary, a prostate biopsy may be conducted to determine if cancer is present. The decision to proceed with a biopsy depends on several factors including the PSA level, rate of PSA change over time (PSA velocity), age, family history, and overall health status 1. Before a biopsy, additional tests may be considered such as free PSA percentage, PSA density, or advanced imaging like multiparametric MRI, which can help identify suspicious areas and potentially reduce unnecessary biopsies 1. Some key points to consider in the evaluation of elevated PSA include:

• The level of PSA correlates with the risk of prostate cancer, with higher levels indicating a greater likelihood of cancer 1
• The use of a specific PSA cut-point in combination with DRE alone can lead to an overestimation of risk in some and underestimation in others, and individualized risk assessment based on a variety of risk factors may be a more appropriate way to characterize the risk of prostate cancer 1
• Prostate biopsy is not a perfect test and may miss cancer when present, and some doctors recommend a second set of biopsies if the first set is negative 1
• The harms of prostate cancer screening are substantial and include false alarms, overdiagnosis, high false-negative rates, anxiety, and discomfort, as well as the risks associated with treatment, such as urinary, gastrointestinal, and sexual problems, and potential cardiovascular events and death 1. It's essential to weigh the potential benefits and harms of screening and treatment, and to consider the patient's preferences, values, and individual risk factors when making decisions about prostate cancer screening and management.

From the FDA Drug Label

About Prostate-Specific Antigen (PSA). Your doctor may have done a blood test called PSA for the screening of prostate cancer. Because finasteride tablets USP decreases PSA levels, you should tell your doctor(s) that you are taking finasteride tablets USP Changes in PSA levels will need to be carefully evaluated by your doctor(s). Any increase in follow-up PSA levels from their lowest point should be carefully evaluated, even if the test results are still within the normal range.

The next step for a patient with elevated Prostate-Specific Antigen (PSA) is to have their doctor carefully evaluate the changes in PSA levels. The doctor should consider the fact that finasteride decreases PSA levels by approximately 50% in patients with BPH. Any confirmed increases in PSA levels from nadir while on finasteride may signal the presence of prostate cancer and should be carefully evaluated, even if these values are still within the normal range for men not taking a 5α-reductase inhibitor 2.

• The patient should inform their doctor about their finasteride treatment when undergoing PSA screening.
• The doctor should carefully evaluate any changes in PSA levels, considering the patient's finasteride treatment.
• The patient should be monitored for prostate cancer while taking finasteride, as the medication may affect PSA test results 2.

From the Research

Next Steps for Patients with Elevated PSA

• If a patient has an elevated Prostate-Specific Antigen (PSA) level, the next step is to determine the cause of the elevation, as PSA levels can be increased by various conditions, including prostate cancer, benign prostatic hyperplasia, and prostatitis 3, 4.
• For patients with PSA levels greater than or equal to 20 ng/ml, biopsy is often recommended to obtain a tissue diagnosis, despite the high positive predictive value of PSA in predicting prostate cancer 5.
• However, in some cases, such as elderly patients with severe co-morbidities or those on chronic anticoagulation, biopsy may not be necessary before androgen ablative therapy, especially if the PSA level is extremely high (greater than 50 ng/ml) 5.
• For patients with elevated PSA and negative biopsy results, repeat biopsy may be necessary, especially if there is a high suspicion of cancer 5.
• Antimicrobial treatment may be considered for patients with elevated PSA and chronic prostatitis, as it may lower PSA levels and reduce the need for unnecessary biopsies 3, 4.
• Follow-up testing and evaluation are crucial for patients with elevated PSA, as poor follow-up may lead to delayed diagnosis and treatment 6.

Considerations for Patient Evaluation

• Patient age, medical history, and comorbidities should be taken into account when determining the next steps for evaluation and treatment 6.
• The use of finasteride, a 5alpha-reductase inhibitor, has been studied as a potential chemopreventive agent for prostate cancer, but its effectiveness is still unclear 7.
• Asymptomatic prostatitis may be a frequent cause of elevated PSA, and antibiotic treatment may be beneficial in reducing PSA levels and avoiding unnecessary biopsies 3.