What is the next best step in management for a patient with a history of gastric cancer and increasing PSA levels?

Management of Rising PSA in a Patient with History of Gastric Cancer

Given the consistent rise in PSA levels over time with a previous negative biopsy, the next best step is to perform a repeat prostate biopsy with at least 14 cores, including the standard 12-core biopsy plus 2 additional cores from the right and left anterior apex. 1, 2

Analysis of PSA Trend

• Current PSA: 10.39 ng/mL (August 2025)
• Previous values show a clear upward trend from 6.26 ng/mL (April 2023) to 12.30 ng/mL (June 2025)
• PSA velocity is concerning, with increases exceeding 0.75 ng/mL/year
• Last prostate biopsy was in September 2020 (negative), but PSA has more than doubled since then

Decision Algorithm for Management

1. Confirm PSA elevation

   • The patient already has multiple elevated PSA measurements showing an upward trend
   • PSA velocity >0.75 ng/mL/year is concerning and warrants urologic intervention 1

2. Imaging before biopsy

   • Multiparametric MRI of the prostate is recommended to identify suspicious lesions 1
   • Consider bone scan since PSA >10 ng/mL 1

3. Biopsy approach

   • Perform extended biopsy with at least 14 cores 2
   • If MRI shows suspicious lesions, use combined approach of MRI-targeted biopsy plus systematic sampling 1
   • Digital rectal examination should be performed prior to and used as a guide for biopsies 3

Important Considerations

• Age and comorbidities: The patient has a history of gastric cancer status post subtotal gastrectomy with chemoradiation, which may affect life expectancy and treatment decisions
• BPH impact: The patient's BPH may contribute to PSA elevation, but the consistent rise suggests the need for further evaluation regardless
• Prior negative biopsy: Despite a negative biopsy in 2020, the significant PSA increase warrants repeat evaluation 3, 1

Potential Pitfalls to Avoid

• Delaying biopsy: With PSA >10 ng/mL and consistent increases, delaying biopsy could miss clinically significant cancer 1
• Inadequate sampling: Standard 12-core biopsy may miss anterior tumors; ensure adequate sampling of all zones 2
• Ignoring PSA velocity: The rate of PSA change is more important than absolute value in some cases 1
• Overlooking gastric cancer history: While rare, metastatic prostate cancer to the stomach or vice versa can occur, though this patient's rising PSA makes primary prostate pathology more likely 4, 5

If the repeat biopsy is negative despite continued PSA elevation, consideration for saturation biopsy would be warranted as the next step 2.