From the Guidelines
I strongly recommend referring the patient to urology for further evaluation of the elevated PSA level, as prostate cancer remains a concerning possibility that requires specialist assessment, despite the normal albumin/creatinine ratio indicating normal kidney function. While an elevated PSA can be caused by several conditions including prostatitis, benign prostatic hyperplasia (BPH), recent ejaculation, or urinary tract infection, the latest guidelines from the European Urology journal 1 suggest that PSA is a continuous parameter, with higher levels indicating a greater likelihood of prostate cancer (PCa).
The patient's elevated PSA level warrants thorough investigation, and the urologist will likely perform additional tests such as a digital rectal examination, possibly repeat the PSA test, and may recommend imaging studies or a prostate biopsy depending on the PSA level, rate of change, and other risk factors. According to the 2024 update of the EAU-EANM-ESTRO-ESUR-SIOP guidelines on prostate cancer 1, multiparametric magnetic resonance imaging (mpMRI) is increasingly important for biopsy optimisation, and risk calculators developed from cohort studies may also be useful in reducing further testing.
It's essential to inform the patient that while an elevated PSA warrants thorough investigation, many men with elevated PSA do not have cancer, and even among those diagnosed with prostate cancer, many cases are slow-growing and may not require aggressive treatment, as noted in the NCCN clinical practice guidelines in oncology: prostate cancer early detection 1. The urologist is best positioned to determine the cause of the elevation and recommend appropriate next steps for diagnosis and management, taking into account the latest research and guidelines, including the prostate-specific antigen best practice statement: 2009 update 1.
From the Research
Patient Evaluation and Referral
- The patient's albumin/creatinine ratio is within normal limits, but the PSA level is elevated, which can be caused by various factors, including prostate cancer 2.
- The worst-case scenario for an elevated PSA level is prostate cancer, highlighting the need for further evaluation.
- Referral to urology for further evaluation is a suitable course of action, as it allows for a more comprehensive assessment of the patient's condition.
Prostate Cancer Screening and Evaluation
- Prostate cancer screening tools, including digital rectal examination (DRE) and PSA testing, are crucial in detecting prostate cancer 3, 4.
- The combination of PSA and DRE is an effective cancer-screening tool, with sensitivity and positive predictive value superior to that of mammography and breast exam 4.
- However, DRE alone has limited accuracy for PCa screening and may result in missed diagnoses or unnecessary biopsies 3.
Follow-up and Biopsy
- Follow-up care after an elevated PSA test can be highly variable, with more than a third of men receiving care that could be considered incomplete 2.
- A delayed diagnosis was not significantly associated with having a pathologically advanced-stage cancer, although it may increase the likelihood of presenting with stage T2C relative to stage T2A or T2B cancer 2.
- Referral to a urologist for further discussion of the risks and benefits of a prostate biopsy is recommended for men with an abnormal DRE or a PSA above 4 ng/ml 4.