From the Guidelines
The patient's PSA trend is concerning and warrants further evaluation, despite being below the traditional 4.0 ng/mL threshold, and I recommend referring the patient to urology for prostate biopsy consideration due to this PSA velocity of >0.75 ng/mL per year, as suggested by the NCCN guidelines 1. The patient's PSA has shown a significant upward trend, nearly doubling from 1.17 in July 2023 to 2.35 in March 2025. This increase in PSA level over time is a more sensitive indicator of potential prostate cancer than absolute PSA values, particularly in men with values below the traditional cutoff, as noted in the NCCN guidelines 1. Some key points to consider in this patient's case include:
- The patient's age and the fact that he has a family history of prostate cancer are not mentioned, but these factors can increase the risk of developing prostate cancer, as stated in the NCCN guidelines 1.
- The patient's low back pain requires separate investigation, as it could potentially represent metastatic disease, though more likely has a benign cause.
- The patient should continue taking Tamsulosin 0.4 mg daily since it's effectively managing his urinary symptoms.
- Order imaging of the lumbar spine (X-ray initially, with MRI if symptoms persist) and basic laboratory studies including CBC, CMP, and alkaline phosphatase to investigate the cause of the low back pain.
- Schedule a follow-up appointment in 2-4 weeks to review imaging results and confirm the urology consultation has been arranged. The concerning PSA trend necessitates prompt evaluation, and the patient's symptoms and test results should be closely monitored to ensure the best possible outcome in terms of morbidity, mortality, and quality of life.
From the Research
Patient Assessment
- The patient is a 53-year-old male who has been taking Tamsulosin 0.4 mg since 3.5.2025, and his urinary symptoms have disappeared.
- He is complaining of low back pain.
- His PSA results are as follows: 2.35 on 3.12.2025,1.26 on 1.5.2024, and 1.17 on 7.13.2023.
Prostate Cancer Screening and Diagnosis
- A study from 1994 2 suggests that digital rectal examination (DRE) and serum prostate-specific antigen (PSA) analysis can be used to diagnose spinal metastasis secondary to prostate cancer in patients with low back pain.
- Another study from 1999 3 found that DRE can detect prostate cancer in men with suspicious DRE findings and PSA levels of 4 ng/ml or less.
- A 2021 study 4 found that DRE provides limited evidence for detecting clinically significant prostate cancer, but may be beneficial in detecting higher-grade disease.
- A 1993 study 5 recommends using DRE, PSA, and transrectal ultrasonography (TRUS) for early detection of prostate cancer, but notes that mass screening for prostate cancer in asymptomatic men cannot be advocated until a decrease in mortality rate is established.
- A 2024 systematic review and meta-analysis 6 found that DRE has a low diagnostic value for prostate cancer detection, and its use as a screening test may not be necessary.
Low Back Pain and Prostate Cancer
- The study from 1994 2 highlights the importance of considering prostate cancer as a potential cause of low back pain in men, particularly those with elevated PSA levels.
- The patient's low back pain and elevated PSA level (2.35) may warrant further investigation, including a DRE and potentially imaging studies, to rule out prostate cancer or spinal metastasis.