Prostate - including PSA

Overview

Advice for Clinicans

Cancer Research UK has an up to date summary for health care professionals about considerations regarding tests for prostate cancer including PSA testing and DRE (see the CRUK guide to prostate cancer):

• Prostate Specific Antigen (PSA) Testing | Cancer Research UK

Please also see the following related pages:

• Urology - 2WW (Remedy BNSSG ICB)
• Lower Urinary Tract Symptoms in men

Testing for prostate cancer

Asymptomatic Men

Public Health England has a guide for GPs:

• Advising men without symptoms of prostate disease who ask about the PSA test

While the UK does not have a national screening programme for prostate cancer, it does have the Prostate Cancer Risk Management Programme (PCRMP) which allows men aged 50 and over to ask their GP for a PSA test regardless if they present with symptoms or not.

Patient Guides

• PSA testing and prostate cancer: A guide for well men aged 50 and over. - link to patient information sheet about the Prostate Cancer Risk Management Programme (PCRMP).
• PSA test | Prostate Cancer UK - includes patient information on benefits and limitations of PSA testing in asymptomatic men.
• MRI scan | Prostate Cancer UK (2) -  information for patients on MRI scan of prostate and interpretation of results including PI-RADS
• Prostate biopsy | Prostate Cancer UK - information for patients on indications, advantages and disadvantages of prostate biopsy.

Symptomatic Men

The Prostate Cancer page in Clinical Knowledge Summaries has a summary including:

• How to assess a person with suspected prostate cancer

Suspect prostate cancer in men who have any of the following symptoms that are unexplained:

• Lower back or bone pain.
• Lethargy.
• Erectile dysfunction.
• Visible haematuria.
• Anorexia/weight loss.
• Lower urinary tract symptoms (LUTS), such as nocturia, frequency, urgency, hesitancy, retention, terminal dribbling, and/or overactive bladder — these symptoms are common in older men and early prostate cancer will not usually produce these symptoms. However, locally advanced prostate cancer may cause obstructive LUTS. 
• Lower back pain, bone pain, weight loss (possible symptoms of advanced prostate cancer.

Local Advice

Local urologists have also given advice about testing in the following specific scenarios:

Asymptomatic men requesting PSA screening

If an asymptomatic man asks for PSA screening then explain PSA is not a recognised screen for prostate cancer (sensitivity 80%, specificity 40-50%).  If elevated then prostate biopsy is  diagnostic test but has risks (>1% risk of infection, 1% risk of significant bleeding) and still only picks up 70-80% of cancers.  Therefore ask patient if they are willing to undergo prostate biopsy before testing PSA.

Older or more frail patients

If age >80 and less than 10 year life expectancy then do not do PSA unless patient has symptoms of metastatic or locally advanced disease and a diagnosis will change management. e.g. bone pain, really bad LUTs and a very abnormal DRE, general clinical decline with weight loss, etc.

Consider Urology - 2WW referral if:

• symptomatic (see above) and PSA 20 or over
• asymptomatic and PSA> 50

Consider Urology urgent referral (to NBT and not GP care) via eRS if:

• asymptomatic and PSA 20-50

Consider obtaining urology advice and guidance as referral may not be needed if:

•  asymptomatic and abnormal PSA <20 

Younger patients

If age 40-49 and family history of prostate cancer then consider PSA at patient request if patient willing to undergo further investigations.

Referral

Suspected prostate cancer

See the Urology -2WW or Red Flag section below for guidelines on referral for suspected urological cancer.

If age > 80 or less than 10 year life expectancy - see guidelines above.

Do not monitor patients in primary care with raised PSA without specialist advice.

Note on Finasteride and PSA testing

Finasteride reduces the PSA level (1) but the effect of finasteride is hugely variable from patient to patient. However, local urologists suggest that generally speaking, it seems a safe option to double the PSA value if a patient is taking finasteride in order to obtain a more reliable reading.

Benign Prostatic Hyperplasia (BPH)

If malignancy is not suspected (PSA normal and prostate feels benign on DRE) then see the LUTS in men section for further advice on management in primary care and when to refer.

Red Flags

Raised PSA

Refer all patients with an age specific raised PSA for investigation via the 2WW pathway (unless a diagnosis is unlikely to change management - see section above).  Do not monitor a raised PSA in primary care without a urological opinion.

Abnormal DRE

If the prostate feels malignant on digital rectal examination then refer via the 2WW pathway (features may include asymmetry, irregularity, nodules and differences in texture e.g firm or hard). Please request PSA as well but do not delay referral.

Re-referral

If a patient has previously been seen in clinic with a raised PSA and discharged, but PSA level has then risen above an agreed threshold for re-referral, then the 2WW pathway should still be used if other criteria are met (or consider urology advice and guidance if re-referral is unlikely to change outcome).

PCN DES for Prostate Cancer

PCNs have been advised to increase awareness of prostate cancer in men at higher risk as part of the work to increase early diagnosis of cancer(1).

PCNs may differ in how they approach this. Prostate Cancer UK does have some advice and materials to support delivery.

Your PCN cancer lead should be able to give further information about how this is being delivered in your practice.

NHS England » Network Contract Directed Enhanced Service – Early Cancer Diagnosis Support Pack

Other prostate conditions

Please see the following pages for advice on management of:

• Acute Prostatitis
• Chronic Prostatitis
• Chronic Pelvic Pain in Men
• LUTS in men
• Haematospermia

Resources

(1) PSA and finasteride - General Practice notebook (gpnotebook.com)

(2) MRI scan | Prostate Cancer UK (information for patients on MRI scan of prostate and interpretation of results including PI-RADS)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.