“The concept of age-related PSA levels is actually out of date” says Brisbane urologic oncologist Dr Ian Vela, at least when it comes to suspecting prostate cancer.
Whereas in the past clinicians would be reassured by levels that remained in the age-related reference range, these days it is considered more important to note the trend of the PSA levels over time as well as the absolute value.
While it is true that the PSA level does tend to increase with age, largely due to benign conditions such as BPH, a trend of increasing PSA levels over time can be evidence of prostate cancer even if levels remain in the reported age-related reference range, says Dr Vela, who spoke at Healthed’s General Practice Education Day in Sydney last month.
According to our national PSA guidelines, endorsed by the majority of Australian authoritative bodies including the RACGP, all men should be offered PSA testing every two years from the age of 50 through to age 69 and further investigation should be done if the total PSA is greater than 3.0ng/mL, regardless of age.
In investigating such patients, checking the free to total PSA ratio can be very useful. A free to total ratio less than 15% is very suspicious for malignancy, whereas ratios greater than 25% tend to suggest a benign cause for the elevated PSA level. In between is what Dr Vela calls the ‘grey zone’ where the result isn’t all that helpful.
Also important in considering which patients to further investigate is family history. A man who has a first degree relative who has had prostate cancer has double to triple the risk of developing the disease. Consequently all male patients need to be asked about family history.
Men who are found to have an acutely elevated PSA after previously having low PSA levels, that is a rapid PSA velocity, need to have an infective cause ruled out first, as this is the most likely cause.
Current PSA guidelines can be found on the Cancer Council website at https://wiki.cancer.org.au/australia/Guidelines:PSA_Testing. Further online and print resources can be at www.healthymale.org.au (formerly known as Andrology Australia).
To hear more of the latest clinical updates on PSA and many other important topics, register now for Healthed’s General Practice Education Day in Melbourne on October 19, Brisbane on October 26 and Perth on November 2.