The role of PSA testing in

Primary Care

JR WilsonFebruary 2020

• Synthesised in prostatic ductal epithelium and acini

• Secreted in lumen of prostatic ducts (seminal fluid – 1 million ng/ml)

• Reaches serum by diffusion into capillaries (serum – up to 4 ng/ml)

• Serine protease

• Part of Human Kallikrein gene family

• Liquefies seminal fluid and thus aids release of sperm

BACKGROUND

PSA produced in other tissues• Periurethral glands of Littre

• Anal glands

• Apocrine sweat glands

• Breast cancer – better prognosis

• Salivary gland neoplasms

• Human breast milk (up to 300 ng/ml)

BACKGROUND

CAUSES OF RAISED SERUM PSA LEVEL

MAIN THREE:

• PROSTATE CANCER

• PROSTATE/URINARY INFECTION

• BENIGN PROSTATIC ENLARGEMENT

OTHERS:

• Urinary retention

• Prostatic massage

• Prostate surgery/biopsy

• Cystoscopy

• Drugs (5⍺-reductase inhibitors)

• Certain exercises (cycling)

• Sexual intercourse – returns to baseline (92% in 24hr, 97% in48hr, 100% in 7 days). Recommendation is to abstain for 48hr before testing

• Rectal examination

• Transrectal ultrasound

• Atraumatic catheterisation

• Haemodialysis

• Exercise (apart from cycling)

THINGS WHICH DO NOT CAUSE AN INCREASE IN SERUM PSA LEVEL ….

PSA NORMAL REFERENCE RANGES

Age (years) PSA range considered normal (ng/mL)

40 - 49 0 - 2.0

50 - 59 0 – 3.0

60 - 69 0 – 3.0*

70 - 79 0 – 5.0

Over 80 ? (probably 0 – 7.0)

* - previously 0 – 4.0, changed in 2016 PHE document

• PSA is the single test with the highest positive predictive value for cancer

• (PSA + DRE) > PSA > DRE

PSA value (ng/mL) Chance of prostate cancer (DRE normal)

Chance of prostate cancer (DRE abnormal)

0 – 4 15% 35%

4 - 10 30% 60%

10 - 20 50% 75%

20 - 50 75% 90%

THE IMPORTANCE OF A RECTAL EXAMINATION WHEN INTERPRETING A PSA VALUE

PROSTATE CANCER PREDICTION TOOLS

• Coral

• Rotterdam Prostate Cancer Risk Calculator

WHAT TO DO WITH A RAISED PSA VALUE.

Scenario 1 – PSA value 4 – 10 ng/mL

Perform rectal examination

Normal

Abnormal

Refer to secondary careExclude UTI

No UTI

UTI present

Repeat PSA 6 – 8 weeks later PSA still raised

Treat

WHAT TO DO WITH A RAISED PSA VALUE.

Scenario 2 – PSA value 10 - 20ng/mL

Perform rectal examination

Refer to secondary care

Check for UTI

WHAT TO DO WITH A RAISED PSA VALUE.

Scenario 3 – PSA value over 20ng/mL

Refer to secondary care

WHAT TO DO WITH AN ABNORMAL-FEELING PROSTATE.

Check PSA

Refer to secondary care

WHEN NOT TO CHECK A PSA LEVEL AS A MATTER OF ROUTINE.

• Symptoms of, or urine dipstick evidence of, a urine infection

• Aged over 75 years

• Life expectancy less than 10 years

• Suspicion of urinary retention

THANK YOU

ANY QUESTIONS …. ?

A PLEA -- please provide as much relevant information as possible when referring

• PSA level(s)• reason for PSA testing?• rectal examination findings?• urine infection excluded?• family history of prostate cancer?