Delayed follow-up care of men with a high PSA found to be common

For any man with a first-time PSA level > 10 ng/ml, there is significant risk for prostate cancer, and early follow-up care — including a repeat PSA test and potentially a biopsy — is probably a priority unless the patient has a life expectancy of 10 years or less.

Turner et al. have recently reported on the follow-up care of men of 50 years of age or more found to have a first-time PSA level of ≥ 10 ng/ml at one of 46 primary care practices over a period of 4.5 years.

The follow-up care included a urology appointment, a repeat PSA test, and potentially a diagnosis of prostate cancer. Excessive delay in follow-up evaluation was considered to be 200 days.

The basic results of this study showed the following:

  • The total number of patients identified was  724.
  • 196/724 men (27 percent) were African American
  • The time from the initial report of a PSA level ≥ 10 ng/ml until actual follow-up averaged 115.2 ± 79.7 days.
  • The unadjusted hazard ratio (HR) for follow-up was shorter for black men than non-black men (HR = 1.23).
  • Black men were more likely to have had prior urology care and had higher index PSA levels than other men.
    • Prior urologic care and higher index PSA levels were both associated with shorter times to follow-up.
  • After adjustment, delay did not differ for black vs non-black race (HR = 1.05)
  • Men aged at least 75 years had a longer time to follow-up than men aged ≤ 74 years (HR = 0.72).

Now it is well understood that African Americans have a greater risk of advanced prostate disease at diagnosis than non-Hispanic white males, and better linkage to urologic care. In spite of this, the current study suggests that, even for black males with a first-time finding of a PSA > 10 ng/ml, follow-up was delayed, on average, by more than 3 months.

It would seem likely that prompt referral of all such patients for urologic follow-up, in significantly less than 3 months, is a potentially important, remediable factor to improve prostate cancer diagnosis, work-up, management, and care for all men, and for African American  men in particular, given their higher risk for both prostate cancer and prostate cancer-specific mortality.

What is not entirely clear from the available information is whether this delay in follow-up care is a consequence of failure to schedule follow-up appointments by the patient or a failure of primary care practices to ensure that follow-up does in fact take place in a timely manner.

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