The role of PSA testing in Primary Care

The role of PSA testing in Primary Care JR Wilson February 2020

BACKGROUND • 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)

CAUSES OF RAISED SERUM PSA LEVEL MAIN THREE: OTHERS: • PROSTATE CANCER • Urinary retention • PROSTATE/URINARY INFECTION • Prostatic massage • BENIGN PROSTATIC ENLARGEMENT • Prostate surgery/biopsy • Cystoscopy • Drugs (5�-reductase inhibitors) • Certain exercises (cycling) • Sexual intercourse – returns to baseline (92% in 24 hr, 97% in 48 hr, 100% in 7 days). Recommendation is to abstain for 48 hr before testing

THINGS WHICH DO NOT CAUSE AN INCREASE IN SERUM PSA LEVEL …. • Rectal examination • Transrectal ultrasound • Atraumatic catheterisation • Haemodialysis • Exercise (apart from cycling)

PSA NORMAL REFERENCE RANGES Age (years) PSA range considered normal (ng/m. L) 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

THE IMPORTANCE OF A RECTAL EXAMINATION WHEN INTERPRETING A PSA VALUE PSA value (ng/m. L) 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%

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/m. L Perform rectal examination Abnormal Normal Exclude UTI present No UTI Treat Repeat PSA 6 – 8 weeks later PSA still raised Refer to secondary care

WHAT TO DO WITH A RAISED PSA VALUE. Scenario 2 – PSA value 10 - 20 ng/m. L Perform rectal examination Check for UTI Refer to secondary care

WHAT TO DO WITH A RAISED PSA VALUE. Scenario 3 – PSA value over 20 ng/m. L 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. • Aged over 75 years • Life expectancy less than 10 years • Symptoms of, or urine dipstick evidence of, a urine infection • 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?