From the Guidelines
A 0.7 year-over-year increase in PSA is concerning for a 66-year-old male and warrants further evaluation by a healthcare provider. This level of increase is significant and should be investigated further to rule out potential prostate cancer. According to the study by Morgentaler et al. 1, a PSA increase of 0.7-0.9 ng/mL in one year is a concern and warrants a repeat PSA measurement in three to six months, followed by a biopsy if there is any further increase.
The patient should schedule an appointment with their primary care physician or urologist promptly for further assessment. The evaluation will likely include a digital rectal examination (DRE) and possibly a repeat PSA test to confirm the elevation. If concerns persist, the physician may recommend additional testing such as a prostate MRI or a prostate biopsy. It's essential to understand that while this PSA velocity is concerning, it doesn't definitively diagnose cancer, as other conditions like prostatitis, benign prostatic hyperplasia (BPH), or recent ejaculation can also cause PSA elevations. However, in men over 65, such a significant annual increase deserves thorough investigation to rule out malignancy, as early detection of prostate cancer significantly improves treatment outcomes. The American Cancer Society guidelines 1 also emphasize the importance of informed decision-making and risk assessment in prostate cancer screening, particularly for men at higher risk, such as those with a family history or African American men.
Key points to consider in the evaluation and management of this patient include:
- Repeat PSA measurement in three to six months to confirm the elevation
- Digital rectal examination (DRE) to assess for any abnormalities
- Consideration of additional testing, such as prostate MRI or biopsy, if concerns persist
- Informed decision-making and risk assessment, taking into account the patient's individual risk factors and preferences.
From the FDA Drug Label
Any confirmed increase from the lowest PSA value while on finasteride tablets may signal the presence of prostate cancer and should be evaluated, even if PSA levels are still within the normal range for men not taking a 5α-reductase inhibitor.
A 0.7 year over year increase in PSA is concerning for a 66 year old male, as any confirmed increase from the lowest PSA value may signal the presence of prostate cancer and should be evaluated, even if PSA levels are still within the normal range for men not taking a 5α-reductase inhibitor 2.
From the Research
PSA Increase Concerns
- A .7 year over year increase in PSA for a 66-year-old male may be a concern, but the provided studies do not directly address this specific question.
- However, studies have shown that digital rectal examination (DRE) can affect PSA levels, with some studies indicating a statistically significant increase in PSA after DRE 3, 4.
- The increase in PSA after DRE may lead to changes in clinical decision-making, such as reaching biopsy trigger cutoffs 4.
Digital Rectal Examination and PSA
- DRE can increase PSA levels, with a mean increase of 0.47 ng/ml and 0.26 ng/ml for total and free PSA, respectively 4.
- The increase in PSA after DRE may be statistically significant, but its clinical significance is unclear 3, 4.
- DRE results should be evaluated in conjunction with other clinical and demographic information to determine their predictive value for prostate cancer 5.
Prostate Cancer Detection
- DRE can be a useful tool for detecting prostate cancer, particularly in men with low PSA levels 6.
- The positive predictive value of a suspicious DRE varies widely, depending on patient characteristics and PSA levels 5, 6.
- A suspicious DRE at confirmatory biopsy, particularly if the DRE at diagnosis was negative, can be a predictor of clinically significant prostate cancer 7.