When should a patient with an elevated Prostate-Specific Antigen (PSA) be referred to urology?

When to Refer a Patient to Urology with an Elevated PSA

Patients should be referred to urology for PSA values above 4.0 ng/ml or for significant PSA velocity changes, specifically increases of 1.0 ng/ml or more in a year. 1, 2

Primary Referral Criteria

• PSA > 4.0 ng/ml: This has been the standard threshold for urologic referral and consideration of prostate biopsy since the introduction of PSA testing 2, 3
• PSA velocity changes:
  • Annual increase ≥ 1.0 ng/ml (regardless of baseline value) 4, 1
  • Increase of 0.7-0.9 ng/ml in one year warrants repeat PSA in 3-6 months and referral if any further increase 4, 1
  • Increase of > 1.5 ng/ml within 2 years 4
  • Increase of > 0.75 ng/ml/year over 2 years 4

Additional Referral Considerations

• Abnormal digital rectal examination (DRE): Any nodule, asymmetry, or areas of increased firmness warrant immediate referral regardless of PSA level 4, 2
• PSA in "gray zone" (2.6-4.0 ng/ml): Consider referral in high-risk patients (family history, African American race) 2
• For patients on testosterone replacement therapy:
  • Refer if PSA rises above 4.0 ng/ml 4
  • Refer if PSA increases by > 1.0 ng/ml in the first 6 months of treatment 4, 1
  • Refer if PSA increases by > 0.4 ng/ml/year after the first 6 months 4, 1

Important Clinical Considerations

• PSA is not cancer-specific: Elevations can occur with prostatitis, benign prostatic hyperplasia, and after procedures 5, 6
• Consider repeat testing before referral: If there's suspicion of prostatitis or recent urologic procedures, consider repeating PSA after 4-6 weeks 7
• Avoid common pitfalls:
  • Don't dismiss elevated PSA in asymptomatic patients - 32% of prostate cancers would be missed if relying on abnormal DRE alone 3
  • Don't automatically attribute elevated PSA to infection without clear symptoms - empiric antibiotics without evidence of infection don't reliably lower PSA 7
  • Don't delay referral for significant PSA velocity changes (≥1.0 ng/ml/year) even if absolute PSA is within normal range 4, 1

Algorithm for PSA Management

1. PSA > 4.0 ng/ml: Immediate urology referral 2, 3
2. PSA 2.6-4.0 ng/ml: Consider referral in high-risk patients 2
3. Any PSA with abnormal DRE: Immediate urology referral 4, 2
4. PSA velocity ≥ 1.0 ng/ml/year: Urology referral regardless of absolute value 4, 1
5. PSA velocity 0.7-0.9 ng/ml/year: Repeat PSA in 3-6 months; refer if further increase 4

Remember that early detection through appropriate referral can significantly impact mortality and quality of life outcomes for patients with prostate cancer 3, 8.