What is the significance of a rising Prostate-Specific Antigen (PSA) level of 0.8 in a patient with a strong family history of prostate cancer?

From the Guidelines

A rising Prostate-Specific Antigen (PSA) level of 0.8 in a patient with a strong family history of prostate cancer is significant and warrants further evaluation.

Key Considerations

• The patient's strong family history of prostate cancer increases their risk for developing the disease 1.
• A PSA level of 0.8 is below the typical threshold for biopsy, but the rising trend is more important than the absolute value 1.
• The National Comprehensive Cancer Network (NCCN) guidelines suggest that men with a family history of prostate cancer should start risk and benefit discussions about offering a baseline PSA at age 45-49 years 1.

Evaluation and Next Steps

• The patient's PSA level and rate of change should be monitored closely, with consideration for repeat testing at 1-2 year intervals 1.
• A digital rectal examination (DRE) may be considered as a baseline test, as it may identify high-risk cancers associated with "normal" serum PSA values 1.
• If the PSA level continues to rise, a biopsy may be necessary to rule out prostate cancer, despite the patient's relatively low absolute PSA value 1.
• It is essential to consider the patient's overall health, age, and other medical problems when deciding on further testing or treatment 1.

From the Research

Significance of Rising Prostate-Specific Antigen (PSA) Level

• A rising PSA level of 0.8 in a patient with a strong family history of prostate cancer may indicate an increased risk of prostate cancer, as familial prostate cancer risk estimates are inflated by clinically insignificant low-risk cancer, diagnosed after prostate-specific antigen testing 2.
• The age-specific probabilities of non-low- and high-risk cancer presented in the study by 2 are more informative than relative risks of any prostate cancer and more suitable to use for counseling men with a family history of prostate cancer.

Prostate-Specific Antigen (PSA) Levels and Prostate Cancer

• PSA measurements are increasingly used to monitor men with localized prostate cancer, but there is little consensus about the method to use 3.
• A study by 4 found that PSA is an androgen-regulated serine protease produced by both prostate epithelial cells and prostate cancer, and is the most commonly used serum marker for cancer.
• Measurement of free versus total PSA can increase specificity for prostate cancer, and tests under development to measure forms of proPSA may further enhance the ability to detect early-stage prostate cancer 4.

PSA Derivatives and Prostate Cancer Diagnosis

• PSA derivatives, including age-specific PSA, PSA velocity, and PSA density, have been discussed as strategies to improve the utility of PSA in the diagnosis of prostate cancer 5.
• A study by 6 found that most prostate cancers in men with a PSA level of < 4.0 ng/mL are clinically significant and PSA-producing, and many of these tumors are high-grade, high-volume, and extraprostatic.

Clinical Implications

• The presence of a strong family history of prostate cancer and a rising PSA level of 0.8 may warrant further evaluation and monitoring, as the risk of prostate cancer is increased in these individuals 2, 6.
• The use of PSA derivatives and other diagnostic tools may help to improve the accuracy of prostate cancer diagnosis and monitoring in these patients 3, 5.