Prostate Cancer Referral Guidance

Summary: If in doubt about the normality of a PSA level or whether one should be measured, obtain advice from a Consultant Urologist

Advice: If in doubt about the normality of a PSA level or whether one should be measured, obtain advice from a Consultant Urologist.
Refer To: Generic Fast-Track referral

PSA has no proven usefulness as a screening test for prostate cancer. If PSA is to be measured as part of a screening process, this should be done following informed discussion with the patient.

In all referrals, please provide all information requested on the referral form to allow us to triage appropriately and allow patients to go straight to tests, please.

Guidance – Age-specific normal PSA ranges

Locally agreed reference ranges:

Age                                      PSA (upper)

40-49 years                         2ng/ml

50-59 years                         3ng/ml

60-69 years                         4ng/ml

70 years & older                   6ng/ml

(consider biological age and medical conditions)

Please note:

Public Health England has given  a threshold of 3ng/ml for patients between 50-69 years.

Ejaculation and mechanical irritation like bike rides may affect the PSA

 

  1. All patients with an abnormal digital rectal examination (DRE) should be referred immediately on a two-week wait pathway (2ww). (Please, provide at least one PSA) (Ref:188-EOECA_PH)

 

  1. For those patients with raised PSA and benign DRE:

Guidance – Exclude infection (Ref:188-EOECA_PH)

  • It is necessary to exclude UTI as a possible cause , as up to 15% of such patients will have a urinary tract infection to account for their elevated result. 
  • Symptoms of UTI like dysuria or temporarily increased LUTS and/or positive dipstick testing is sufficient, and if infection is suspected, treat appropriately and repeat the PSA six weeks later.
  • In those without infection, follow the management guidelines below –

Asymptomatic

1. Patients with PSA ≥10 refer as 2ww

(Ref:188-EOECA_PH)

2. Patients with PSA <10 repeat PSA in 4 weeks before 2ww referral

[Ref:188-EOECA_PH: Patients with a single borderline raised PSA (We interpret this as PSA <10), a repeat PSA in 4 weeks is recommended before 2ww referral to exclude physiological or short-term illness as a cause of the isolated PSA rise]

Symptomatic

All symptomatic patients with PSA above age specific range refer as 2ww (Ref:188-EOECA_PH)

Guidance – Symptoms

To help GPs counsel patients regarding their risk and to give re-assurance, the following can be used as guidance. We would advise GPs to use clinical judgement and consider the wider clinical presentation:

  • Symptoms likely related to presence of a cancer in the urinary tract (not necessarily prostate cancer): Haematuria, weight loss and bone pain
  • LUTS:

Isolated LUTS without a raised PSA or abnormal DRE is usually not a sign of prostate cancer

Temporarily increased LUTS may be a symptom of UTI.

Longstanding stable or evolving LUTS are rarely a symptom of progressing prostate cancer

  • Acute urinary retention:

PSA is often raised if taken during the episode of retention and after catheterisation. Yet, we would advise to check the PSA within about 4 weeks.

  • Chronic urinary retention:

This requires referral to the urology department. It is very helpful to include a recent PSA test.

  • Pelvic pain:

This can be caused by multiple conditions. If the symptoms suggests a cause relating to the urinary tract, a PSA test should be taken. PSA may be raised during an acute exacerbation.

This guidance is supported by an East of England Cancer Alliance ‘Notification to all GP’s in the East of England – Elevated PSA Referral Guidelines’ (Ref:188-EOECA_PH) where indicated, international guidance and local consensus based on published evidence.

 

Useful links

CRUK poster on PSA screening

BMJ 2018 article: Do men with lower urinary tract symptoms have an increased risk of advanced prostate cancer? 

 

 

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