Prostate Cancer / Elevated PSA

Introduction

Radical curative treatment is usually considered for those with at least 10y life expectancy; typically, surgery is undertaken for those under 70 years and radiotherapy for those under 75.
Patients aged 80 and over usually only receive hormone therapy if there is evidence of metastatic disease.
PSA testing is not recommended in men over 80 years unless there are symptoms suggestive of metastatic disease (bone pain, unintended weight loss, lethargy).

Red flag features¹

Suspect prostate cancer in men with unexplained:

Low back or bone pain
Lethargy
Erectile dysfunction
Unintentional weight loss
Visible haematuria

PSA testing

Whilst men are entitled to undertake PSA testing after counselling, the benefits of population screening are unproven.
Adopt a shared decision-making approach when considering PSA testing.
48-hour pre-test advise patients to avoid:
- Strenuous/vigorous activity
- Ejaculation
Wait 6 weeks before testing PSA if UTI or urological intervention, i.e. prostate biopsy.
A routine DRE has no significant effect.

Referral

Suspected Cancer Pathway – Prostate:

Minimum required information

Up-to-date blood tests including eGFR and PSA
Any reasonable adjustments required

Refer via the Fast Track Suspected Urology Cancer pathway if:

Prostate feels malignant on DRE
- Predictive value of DRE alone is poor, so all referrals should include a PSA test
Single PSA level over 10ng/ml, and above age-specific reference range, after exclusion of UTI
Two PSA results, 6 weeks apart (but preferably no more than 10 weeks apart), with level under 10ng/ml and above age-specific reference range, after exclusion of UTI

See the Fast Track Suspected Urology Cancer referral form for PSA age-specific reference ranges.

Referral options for men 80 years and over with a raised PSA and no signs of metastatic disease

For men 80 years and over with PSA between 7.5 and 20ng/ml and there are no signs of metastatic disease, repeat PSA ONCE after 6 months in primary care, prior to any secondary care referral.

When PSA is repeated, refer:

Urgently if PSA has more than doubled, or
Via Fast Track Suspected Urology Cancer pathway if PSA now ≥20ng/ml²

Please note:

Referrals may be made as per the suspected cancer referral criteria. However, as the biological rate of progression for prostate cancer is less than other urological malignancies, routine referrals may be more appropriate in some cases.

Supporting Information and References

For professionals:

NICE CKS: Prostate cancer, September 2024

NICE [NG131] Prostate cancer: diagnosis and management, December 2021

NICE CKS: Urological cancers – recognition and referral, February 2021

For patients:

PSA testing and prostate cancer: information sheet

NHS: Should I have a PSA test?

Prostate Cancer UK

References

Page Review Information

Review date	12 September 2024
Next review date	12 September 2026
GP speciality lead	Dr Laura Vines
Contributors	Miss Elizabeth Bright, Consultant Urologist RCHT