Prostate Cancer / Elevated PSA
The RCHT urology team conducted a recent department audit of men over 80 referred with a raised PSA via the 2WW pathway. 64% received no further investigations or treatment and were discharged at that appointment. As such only those that are likely to be given urgent treatment (hormones) require a 2WW appointment. Those with a PSA 10-20 would benefit from a consultation with a urologists to discuss watchful waiting and patient reassurance, for which it is more appropriate for this to be an urgent (non-2WW) appointment. Thus these men will be seen within 6 weeks rather than 2
2WW criteria
1. Hard irregular prostate on DRE- Predictive value of DRE alone is poor so all referrals should include a PSA test.
2. Clinical suspicion of metastatic prostate cancer
3. Raised/rising age specific PSA (2 PSA tests) UTI excluded
- PSAs should be repeated for confirmation ~ 6 weeks apart. Strenuous activity eg. cycling and ejaculation should be avoided for 48h pre-test (a routine DRE has no significant effect). Where UTI is suspected wait at least 6 weeks before (re)testing. (PSA range on lab report)
Management prior to referral:
- Prostate cancer (PCa) management is contentious. Whilst men are entitled to undertake PSA testing after counselling (NHS PCa Risk management programme) the benefits of population screening are unproven.
- PSA testing should not be undertaken without discussion with the patient.
- Referrals may be made under the 2WW criteria above. However, as the biological rate of progression for PCa is less than other urological malignancies, routine referrals may be more appropriate in some cases.
- Radical curative treatment is usually considered for those with at least 10y life expectancy, typically surgery is undertaken for <70y and radiotherapy <75y olds. Such patients with a PSA in excess of the age specific range, (even if only marginally eg< 10 ug/L) should be referred to consider prostate biopsy. Referral is also appropriate for men in 70s, but they are less likely to have active treatment.
- Those above 80y typically receive hormone therapy only with evidence of metastatic disease, urinary symptoms or a PSA>50 ug/L. In the absence of such suspicions avoid PSA testing (NICE)
References:
NICE NG12, Suspected Cancer recognition & referral, June 2015
NICE, NG131 Prostate Cancer, May 2019
NICE CKS PSA testing
https://cks.nice.org.uk/topics/prostate-cancer/diagnosis/psa-testing/
Patient resources
PHE Patient information sheet
https://www.nhs.uk/conditions/prostate-cancer/should-i-have-psa-test/
Contributors
Mr Christopher Blake, Consultant Urologist, RCHT
Dr Bridgitte Wesson, GP * Kernow RMS GP Lead for Urology guidelines
Reviewed: March 2022
Next review due : March 2023