What is the next step for an elderly man with an elevated Prostate-Specific Antigen (PSA) level of 25?

Management of an Elderly Man with PSA of 25

The next step for an elderly man with a PSA of 25 ng/mL should be a transrectal ultrasound-guided prostate biopsy with a minimum of 10-12 cores. 1, 2

Risk Assessment

• A PSA level of 25 ng/mL is significantly elevated and confers a greater than 67% likelihood of harboring prostate cancer, regardless of digital rectal examination findings 1
• The proportion of men with metastases to pelvic lymph nodes is approximately 36% when PSA levels exceed 20 ng/mL 2
• The proportion of men with pathologically organ-confined disease is only about 50% when PSA levels exceed 10 ng/mL 2
• At this PSA level, the risk of clinically significant prostate cancer is very high, and watchful waiting without a definitive diagnosis is not appropriate 1

Diagnostic Approach

• Confirm the elevated PSA with a repeat test before proceeding to biopsy to verify the elevation 1
• Perform a digital rectal examination (DRE) as part of the complete evaluation 1
• Consider additional PSA testing such as percent free PSA to improve specificity for prostate cancer detection 1
• Proceed to transrectal ultrasound-guided prostate biopsy with a minimum of 10-12 cores under antibiotic cover and local anesthesia 2, 1
• Consider multiparametric MRI to guide the biopsy and improve diagnostic yield, particularly if previous biopsies have been negative 2, 1

Imaging Considerations

• At this PSA level, imaging for metastatic disease is indicated before or concurrent with biopsy 1
• Appropriate imaging modalities include:
  • Technetium bone scan 1
  • Thoraco-abdominal CT scan 1
  • Whole-body MRI or choline PET/CT 1

Important Considerations

• Even in elderly patients, a PSA of 25 warrants thorough evaluation as it indicates a high risk of clinically significant disease 1
• The patient should be informed about the risks and benefits of prostate biopsy, including the 4% risk of febrile infections 1
• If prostate cancer is confirmed, treatment options will depend on staging, Gleason score, and the patient's overall health status 1
• Even in elderly patients, if they are in good health with minimal comorbidities, they may be candidates for definitive treatment with curative intent 1

Common Pitfalls to Avoid

• Do not dismiss an elevated PSA in an elderly patient without further evaluation, as approximately 1 of 7 men with PSA levels less than 4 ng/mL still have prostate cancer, highlighting the importance of thorough evaluation at much higher levels 1
• Do not assume that age alone precludes treatment; individualized assessment of health status and life expectancy is necessary 2
• Do not forget to rule out other causes of elevated PSA, such as prostatitis, which can cause dramatic increases in PSA levels 1
• Do not proceed with testosterone therapy (if being considered) until prostate cancer has been ruled out 1