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Case History

Image not available. A 73-year-old white man sees his general practitioner (GP) as he thinks he might have prostate cancer. His medical history is unremarkable other than osteoarthritis. He has prostatism but has no history of urinary tract infection. On digital rectal examination (DRE) his prostate is found to be symmetrically enlarged. His prostate-specific antigen (PSA) level is 5.5 ng/ml and was checked 1 week after the rectal examination.

What are the causes of raised PSA?

What is the importance of the PSA level?

What is the likely diagnosis in this patient?

Background

Image not available. Prostate cancer is being detected with increasing frequency, due in part to the widespread availability of serum PSA testing, although the incidence was increasing even before its introduction.

A 'prostate cancer risk management programme' was published in 2002 by Watson et al. on behalf of Cancer Research UK.1 The programme aims to help the primary care team in giving clear and balanced information to men who ask about testing for prostate cancer.

What are the causes of raised PSA?

The PSA may be raised for many reasons (Box 20.1) and these should be considered prior to a PSA test. In primary care, DRE is usually not recommended as a screening test in asymptomatic men. In men with symptoms, the PSA should be tested before a DRE. If the DRE is done before, the PSA test should be delayed for a week. This issue, however, is controversial and some feel that a PSA can be done immediately after a DRE.2

Box 20.1 Benign causes of raised PSA

  • Benign prostatic hypertrophy

  • Acute prostatitis

  • Subclinical inflammation

  • Prostate biopsy in previous 6 weeks

  • Cystoscopy

  • Trans-urethral resection of the prostrate

  • Urinary retention

  • Ejaculation

  • DRE

  • Perineal trauma

  • Prostatic infarction

Discussion

What is the importance of the PSA level?

Image not available. Key issues to be discussed with the patient are as follows.

PSA testing aims to detect localized prostate cancer when potentially curative treatment can be offered. It should be made clear that PSA testing is controversial and that professionals disagree on the usefulness of the test for population screening.3 To date there is no good evidence that screening for prostate cancer using PSA testing reduces mortality.4

The traditional cut-off level for the PSA is 4.0 ng/ml,5 however, some men (up to 20%) with clinically important prostate cancer will not have a raised PSA; and in about two-thirds of men with a raised PSA, prostate cancer is not diagnosed. Many modifications of the PSA test have been attempted, including lowering of cut-offs, serial PSA tests, usage of PSA velocity-PSA density-free PSA-complexed PSA, age-specific reference ranges, and race-specific reference ranges. However, no consensus has been reached and none of the approaches have resulted in a reduction ...

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