What is the significance of a Prostate-Specific Antigen (PSA) level of 15.1 in a 90-year-old patient?

From the Guidelines

For a 90-year-old man with a PSA level of 15.1 ng/mL, I strongly recommend against immediate prostate biopsy and instead suggest a urology consultation to discuss the risks and benefits of further testing, considering the patient's advanced age and potential for significant harm from over diagnosis and treatment. The elevated PSA requires evaluation, but age and life expectancy should be considered before pursuing aggressive diagnosis or treatment 1. The urologist should assess overall health status, comorbidities, and discuss the risks and benefits of further testing. At 90 years old, watchful waiting or conservative management may be more appropriate than definitive treatment for prostate cancer, even if diagnosed. The PSA elevation could be due to benign prostatic hyperplasia (BPH), prostatitis, or prostate cancer. Basic laboratory tests including urinalysis, kidney function tests, and a digital rectal examination should be performed. Symptom management with alpha-blockers like tamsulosin 0.4mg daily or 5-alpha reductase inhibitors like finasteride 5mg daily may be appropriate if urinary symptoms are present. The decision-making should prioritize quality of life and avoiding interventions that may cause more harm than benefit given the patient's advanced age.

Some key points to consider in this patient's management include:

• The likelihood of over diagnosis increases with age, and modeling studies have estimated that among men aged 80 years and older, three-fourths or more of cases detected by PSA screening with PSA less than 10 and Gleason score 6 or below are over diagnosed 1.
• The Panel does not recommend routine PSA screening in men over age 70 years or any man with less than a 10 to 15 year life expectancy, with a recommendation strength grade of C 1.
• The quality of the evidence for harm remains high or at least higher than that of the benefit, and the certainty in the balance of harm and benefit justifies a recommendation against routine PSA-based screening in this age group 1.
• A prostate biopsy is usually well tolerated but can cause serious problems such as rectal or urinary hemorrhage, infection, or urinary retention, and the risks and benefits of biopsy should be carefully considered in this patient population 1.

Given the patient's advanced age and the potential for significant harm from over diagnosis and treatment, a conservative approach prioritizing quality of life and avoiding interventions that may cause more harm than benefit is recommended. The patient's overall health status, comorbidities, and preferences should be carefully considered in the decision-making process.

From the Research

Prostate-Specific Antigen (PSA) Levels in 90-Year-Olds

• PSA levels are used to screen for prostate cancer, but elevated levels can also be caused by other conditions, such as benign prostatic hyperplasia (BPH) or prostatic inflammation 2.
• A study found that men with symptomatic BPH and erectile dysfunction had significant inflammation of the prostate, which can cause a spurious rise in PSA levels, resulting in unnecessary biopsies 2.
• The positive predictive value of PSA is affected by asymptomatic prostatic inflammation, which can be diagnosed by prostatic fluid interleukin-8 (IL-8) levels 2.

PSA Levels and Prostate Cancer Risk

• A study found that five-alpha-reductase inhibitors (5ARIs) reduce the risk of prostate cancer, but may increase the risk of high-grade disease in men who are undergoing regular screening for prostate cancer using PSA and digital rectal examination 3.
• The study also found that the effects of 5ARIs on prostate cancer risk are consistent across race, family history, and age, but are limited to men with baseline PSA values <4.0 ng/mL 3.
• Another study found that patients with high-risk prostate cancer and PSA levels ≤15 ng/mL treated with permanent interstitial brachytherapy had excellent biochemical progression-free survival and cause-specific survival rates 4.

Treatment Options for BPH and Prostate Cancer

• Combination treatments with α-blockers and 5ARIs have been investigated extensively in high-quality trials and have been shown to be effective in treating BPH, with acceptable rates of side effects 5, 6.
• Other combination treatments involving 5ARIs and other classes of medications, such as anticholinergics, b3 agonists, and PDEI, have been shown to be beneficial in the short term, but longer-term studies are needed to fully establish their role 6.