GP Questions: Raised PSA and Prostate Cancer

Mr Alan Doherty

The main question for GPs: raised PSA and prostate cancer

By Alan Doherty, consultant urologist, Birmingham Prostate Clinic

I am pleased to have another opportunity to meet GPs for an educational event on November 17. I attend these events as often as possible, because we need effective connections between the GP surgery and hospital. Meeting each other face-to-face for full and open discussion is essential to making it all working together.

I’ve been a consultant urologist for 15 years and the main question which comes up at these events has not changed: GPs want guidance on when to refer after a patient has a raised PSA. Of course, sometimes the question is clear cut – if PSA result is high above aged-related thresholds and/or digital rectal examination (DRE) reveals clear abnormalities.

But when to refer is often not clear cut and today’s GPs are increasingly being scrutinised on the criteria for their hospital referrals with the emphasis on primary care management where possible. GPs are very focused on getting this challenging balance right; no-one wants to miss significant cancer or an opportunity for curative treatment.

Both GPs and urologists are very aware of the shortcomings of the PSA test giving us a high level of false positives (raised results where there is no cancer) and the risk of false negatives (low PSA reading where cancer is present). Nevertheless, we also know that when the PSA test is combined with advanced diagnostics such as the PCA3 test and enhanced MRI (before biopsy), we have a much more accurate and personalised pathway for assessing prostate cancer.

One of the issues we do see on a fairly regular basis is men remaining on active surveillance for longer than they probably should. These are men who are initially well within the boundaries of low risk prostate cancer when they first present to their GP or urologist, but who have moved to medium/high risk prostate cancer by they receive treatment. This of course can limit and compromise curative options (resulting in worse side-effects).

Key factors to bear in mind would be:

  • Even if a patient is within aged related PSA thresholds, constant increase should be sufficient for a referral
  • Family history is very significant: if there is a first degree relative who has had the disease (especially if diagnosed under the age of 60), this is sufficient for referral even if PSA is on the borderline of threshold
  • Side-effects of prostatectomy have been reduced to such a degree that the procedure is very well tolerated by older men in good health. At BPC, men up to the age of 78 have had the procedure with very good outcomes: bear this is mind in terms of management – older men are seeking curative treatment options