I am requesting an eConsult for this 84 y.o. man and the existing templates do not apply.
My clinical question: 84 yo man with history of elevated PSA and abnormal prostate biopsy in the past. What screening/surveillance should he have given the abnormal biopsy in the past. Thank you.
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Schedule this patient for a visit with the specialty. The patient understands that they may be contacted by the specialty practice to schedule an appointment.
Most recent PSA 1.5 on 3/4/2025. Prostate biopsy from 2014 with one focus high grade PIN, which is currently deemed non-significant.
PSA is reassuring and given advanced age there is likely little utility in continued PSA screening unless life expectancy is 10 years or greater. See below but in general PSA screening is not continued past age 70 as a routine and is rarely indicated for patients above age 80.
The 2023 American Urologic Association/Society of Urologic Oncology Guideline on prostate cancer recommends that men may consider PSA screening starting at age 45 and continuing on an every 2-4 year basis until age 69. Men with risk factors (specifically, African ancestry, genetic conditions linked to prostate cancer such as BRCA gene mutations, and/or a family history of prostate cancer diagnosed before the age of 60) should consider screening starting at age 40.
At age 70 and older, shared decision making should be used to determine whether or not continued PSA testing is warranted. The most useful metric to aid this decision making process is 10 year life expectancy. When a man’s life expectancy drops to 10 years or less and/or he would not consider surgical or radiation based therapy for any prostate cancer diagnosed the value of PSA screening drops precipitously.
Discussions about life expectancy can be an uncomfortable to have with patients but an honest assessment of longevity, particularly considering serious comorbid conditions such as dementia and/or advanced heart, renal, lung, or liver disease. Longevity calculators, particularly those specific to certain disease states, may be useful in aiding these decisions.
The AUA 203 guideline furthermore recommends that PSA be repeated before any additional diagnostic procedures, including biopsy, are performed. For this reason it is appropriate to repeat a PSA (consider total and free) no less than 4 weeks after the initial screening PSA for confirmation purposes. It is also appropriate to perform a digital rectal examination and to rule out other etiologies for elevated PSA such as recent urethral instrumentation (catheter placement), anal receptive intercourse, and/or urinary tract infection as these non-malignant entities will tend to drive PSA elevation. Careful history and a urinalysis with reflex microscopy and culture is sufficient to screen for these entities.
The AUA 2023 guidelines specify age based thresholds for what is considered elevated; this is based on most studies identifying age-varying thresholds specify threshold values of 2.5 ng/mL for people in their 40s, 3.5 ng/mL for people in their 50s, 4.5 ng/mL for people in their 60s, and 6.5 ng/mL for people in their 70s.
UCSF faculty, in collaboration with the San Francisco Cancer Initiative (SFCAN), have advanced alternative PSA cut points and testing protocols for screening for prostate cancer. This guidance is more aggressive about detection and may help reduce prostate cancer specific mortality with the attendant risk of increased treatment-related morbidity.
Specific recommendations from SFCAN include:
When considering referral for consideration of prostate biopsy, referring physicians should take both sets of recommendations under advisement and engage in shared decision making on PSA screening and referral
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This eConsult is based on the clinical data available to me and is furnished without benefit of a comprehensive evaluation or physical examination. The above will need to be interpreted in light of any clinical issues, or changes in patient status, not available to me at the time of filing this eConsult. Please alert me if you have further questions.
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