What are the guidelines for Prostate-Specific Antigen (PSA) testing and treatment?

Guidelines for Prostate-Specific Antigen (PSA) Testing and Treatment

PSA screening should be offered to men aged 45-69 years after a thorough discussion of potential benefits and harms, with decisions based on individual risk factors, preferences, and life expectancy. 1

Screening Recommendations

Who Should Be Considered for PSA Screening

• PSA testing should be offered to men aged 45-75 years after informed discussion about potential benefits and harms 1
• Begin PSA screening discussions earlier for high-risk populations:
  • African-American men 1
  • Men with positive family history (especially first-degree relatives diagnosed with prostate cancer before age 65) 1
• Screening should be individualized for men aged 55-69 years with at least a 10-year life expectancy 1, 2
• PSA screening is generally not recommended for men aged 70 years and older due to limited benefit and increased potential harms 1, 2

Screening Frequency and Protocol

• For men with PSA values below 1 ng/mL, testing should occur every 2-4 years 1
• For men with PSA values at or exceeding 1.0 ng/mL, testing should occur at 1-2 year intervals 1
• Avoid PSA testing within 48 hours of ejaculation or vigorous exercise (such as cycling) as these may cause false positive elevations 1

Interpretation of PSA Results

PSA Thresholds and Additional Testing

• Consider prostate biopsy when PSA exceeds 3.0 ng/mL, but do not base decisions on PSA cutpoint alone 1
• Additional biomarkers that improve biopsy specificity should be considered before biopsy in men with PSA >3 ng/mL:
  • Percent free PSA (%fPSA) 1, 3, 4
  • 4Kscore 1
  • Prostate Health Index (phi) 1
  • PSA density (PSA divided by prostate volume) 5
• A %fPSA cutoff of 25% or less is recommended for patients with PSA values between 4.0 and 10.0 ng/mL and a normal digital rectal exam 4
• Lower %fPSA values are associated with higher risk of clinically significant cancer 3, 4

Risk Assessment Considerations

• Digital rectal examination (DRE) should be performed alongside PSA testing to exclude locally advanced prostate cancer 1
• PSA velocity (rate of change over time) may help identify men at higher risk of prostate cancer 1
• PSA density (PSA level divided by prostate volume) can improve discrimination between benign conditions and cancer 5
• Consider a patient's overall health status, comorbidities, and life expectancy when interpreting PSA results 1

Monitoring After Initial Testing

Follow-up of Abnormal Results

• Patients with elevated PSA should undergo further evaluation with additional biomarkers or imaging before proceeding to biopsy 1
• Prostate biopsy is typically performed transrectally under ultrasound guidance with antibiotic prophylaxis and local anesthesia 1
• Patients should be counseled about potential biopsy complications including pain, bleeding, and infection 1

Monitoring in Special Populations

• For men on testosterone replacement therapy:
  • Baseline PSA and DRE should be performed before initiating therapy 1
  • PSA should be monitored every 3-6 months for the first year and annually thereafter 1
  • Consider prostate biopsy if PSA rises above 4.0 ng/mL or increases by more than 1.0 ng/mL in any year 1

Treatment Considerations

PSA Monitoring After Treatment

• After radical prostatectomy, PSA should be undetectable (<0.2 ng/mL) within 8 weeks 1
• Treatment failure after prostatectomy is defined as detectable PSA (≥0.2 ng/mL) with a subsequent rising value 1
• For patients receiving hormonal therapy, testosterone levels should reach a plateau or return to baseline before interpreting PSA changes 1

Treatment Suspension and Reinitiation

• For patients with non-metastatic castration-sensitive prostate cancer receiving treatment, therapy can be suspended if PSA becomes undetectable (<0.2 ng/mL) after 36 weeks 6
• Treatment should be reinitiated when PSA increases to ≥2.0 ng/mL for patients who had prior radical prostatectomy or ≥5.0 ng/mL for patients who had prior primary radiation therapy 6

Common Pitfalls and Caveats

• PSA levels can be elevated in benign conditions such as benign prostatic hyperplasia (BPH), prostatitis, and after prostatic manipulation 1
• Approximately 25% of men with BPH have PSA values greater than 4 ng/mL 1
• Certain medications (finasteride, dutasteride) can lower PSA levels and should be considered when interpreting results 1
• PSA screening has potential harms including false-positive results, overdiagnosis, and complications from unnecessary biopsies and treatments 1, 2
• Treatment complications may include erectile dysfunction, urinary incontinence, and bowel symptoms 2