Getting a repeat PSA test prior to biopsy … value now confirmed

For quite a while now The “New” Prostate Cancer InfoLink and many others have been advising men who get a single, somewhat elevated PSA test result to get that test repeated before they make any decisions about what else they may need to do. The validity of this guidance has now been confirmed in a paper by Lavallée et al., just published yesterday in the current issue of the Mayo Clinic Proceedings. (A media release issued by The Ottawa Hospital in Ottawa, Ontario, Canada, provides additional information.)

Lavallée and his colleagues set out to investigate whether simply repeating the PSA test in men with an elevated PSA level had an impact on risk for prostate biopsy and cancer diagnosis. This was a prospective, single-center, cohort study conducted between April 1, 2008, and May 31, 2013. It enrolled men referred to the Ottawa Regional Prostate Cancer Assessment Clinic who had initial PSA levels on a first test between 4 and 10 ng/ml.

Here are the basic study findings:

  • The study included 1,268 patients.
  • Repeat PSA test results were normal in 315/1,268 patients (24.8 percent).
  • Compared to men who still had elevated PSA levels on repeat biopsy, the men with normal results
    • Were younger (61.5 ± 8.2 years vs 65.2 ± 8.2 years; P < 0.001)
    • Had lower referral PSA levels (5.5 ± 1.4 ng/ml vs 6.6 ± 1.5 ng/ml; P < 0.001)
    • Were less likely to undergo prostate biopsy (relative risk [RR] = 0.42) on multivariate analysis
    • Were at lower risk for cancer diagnosis (3 percent vs. 19 percent; RR = 0.22)
    • Were at lower risk for a Gleason score of 7 or higher (RR = 0.16)

Lavallee et al conclude that:

Routinely repeating a PSA test in patients with an elevated PSA level is independently associated with decreased risk of prostate biopsy and prostate cancer diagnosis. Men with an elevated PSA level should be given a repeated PSA

Quoted in the media release from The Ottawa Hospital, the paper’s senior author, Dr. Rodney Breau, stated that:

It is clear to me that any man with an abnormal PSA test should have this test repeated before a decision to biopsy. Some doctors and patients may be worried about missing a significant cancer diagnosis if they forgo a biopsy after conflicting test results, but our study shows this is very unlikely. It is also important to remember that the PSA test is just one factor we evaluate when deciding to do a biopsy, and these decisions are always made together with the patient, and can be revisited if risk factors change.

We should be clear that the situation is not necessarily the same for men with PSA levels > 10 ng/ml or for men with other associated signs and symptoms of prostate cancer (e.g., a positive rectal exam). However, a delay of a couple of weeks or a month to get a repeat PSA test is unlikely to have meaningful impact on the majority of men with an early-stage, localized prostate cancer.

10 Responses

  1. From an epidemiological standpoint, a health-policy standpoint I think it is entirely reasonable to advocate for such a treatment delay in order to get an extra PSA test after a couple of months, which in fact was my diagnosis protocol after an initial 9 ng/ml PSA reading. But in retrospect I wish my urologist, who knew I could well afford to have it at my own out-of-pocket expense, had suggested an immediate trip to the nearest high-quality MRI imaging facility. If the resulting MRI image had shown up the large Gleason 9 prostate cancer node (as did the actual MRI which I had almost 6 months later) my actual treatment (RT + 2 years of ADT) could have and would have started 5 months earlier. Five years on, there has been no biochemical progression and I hope there won’t be. So likely (I hope) the treatment was done in time and was curative.

    As a taxpayer, I wouldn’t be thrilled about the idea of Medicare supporting a rush to expensive MRI imaging by guys whose PSA was raised a little. But as a patient, it’s worth bearing mind that high-risk prostate cancer tumors will, over an unpredictable period of time, lead to a disease state which is no longer curable (although new drugs can slow down the inevitable). The sooner it’s treated the more likely it’s treatable, whether by surgery or radiation. If you can afford to override the insurance and pay your own way, it may be worth shelling out a couple of big ones, if only for the peace of mind.

  2. Ken’s comment above is extremely important to the whole question of what we should be doing as a society as opposed to what individual patients may feel the need to do.

    As a society, we simply are not going to be able to afford to send every patient with a slightly elevated PSA level off to get a multiparametric MRI prior to biopsy. Quite apart from the costs involved, we don’t have the available technology at enough centers, nor to we have a sufficiency of uroradiologists capable of overseeing such MRIs and reading the resulting MRI scan data with a high level of accuracy based on the PI-RADS guidelines.

    We need some very clear guidelines about who actually needs such MRI scans, why, and why they should be covered by insurance.

  3. Getting a repeat PSA test after the initial results before moving forward in the treatment scheme is worth while — MRI/ultrasound/biopsy. If the value is “just above” the limit, waiting a month is worth the wait — either to confirm or see if it was due to factors affecting a raise in the value. Being informed of activities causing the PSA value to rise and what needs to be avoided at least 48 hours before the blood is drawn again needs to be passed on to the patient.

    In my case I had an initial PSA — just above the old cut-off value — and was supposed to have one before radiation started, which was never drawn, which amazed the radiologist when told in a weekly meeting during treatment, so I have no baseline to determine my drop curve rate. Also I was never told what to avoid or for how long before a PSA was to be drawn. For me a repeat PSA with that knowledge probably would have been below the old cut-off value. I had no symptoms or family history.

    True, I understand there are a lot of factors involved, but a month wait with knowledge may “save” some men from “aging” early. Or after a month and repeat test, confirm that there is something worth looking into.

  4. My 68-year-old husband sadly passed away October 17 of this year. Originally, his PSA in 2009 was 3.5 at his primary care physician’s office. His physician assistant was the one saw my husband to give him the PSA score.

    A year before, in 2008, his PSA had been 2.0, but according to this P.A., there was “no reason to worry because it was under 4.0.” She paid no attention to the fact that my husband’s PSA increased in 11 months from 2.0 to 3.5. He was not referred to an urologist; he did not have a prescription for antibiotics in case it was infection; and she did not suggest that he repeat the PSA test. She said for him to return in 4 months. At that rate (velocity?) in 4 months, who knows how high it would have been.

    The next time he had a PSA test, which was July 2010, his PSA had risen to 20.4! The diagnosis was stage IV prostate cancer! If the physician who should have been overseeing his P.A. had checked her work, and if he had immediately been referred to an urologist, I feel strongly my husband would be here to enjoy the holidays with our grandchildren. Feedback? What should have been done differently? Or was the P.A. correct in her reply “but it’s under 4”?

    I would sincerely appreciate some of you, men, commenting on this situation, please.

  5. Dear Mrs. Bishop:

    Your husband appears to have been given less than stellar guidance. There is no one absolute PSA level (like 4.0 ng/ml or higher) that indicates risk for prostate cancer. It is relatively unusual, but men can sometimes be diagnosed with aggressive forms of prostate cancer with PSA levels of 2.0 ng/ml or even lower. It can be very hard to identify such cancers early. However, …

    Many specialists would tell you that a man whose PSA rose from 2.0 to 3.5 over the course of a year should either have been referred immediately to a urologist or should have been given a repeat PSA test a month later and then referred to a urologist if the PSA level was still of the order of 3.5 ng/ml or higher. Since your husband appears to have had no indication of a urinary tract infection, there would have been no reason to give him any antibiotic therapy.

    If he had been referred to a urologist in 2009, it is possible (but not certain) that he could have been treated with greater effect at that time. However, the fact that he was diagnosed with Stage IV prostate cancer just 12 months later does suggest that he had a very aggressive form of cancer that might already have micrometastasized by 2009, in which case his long-term outcome would probably have been similar to the actual consequence.

    Obviously, I am very sorry for your loss. Did your husband receive the best possible guidance? Well, probably not. We have known for many years now that there is no formal PSA cut-off point for risk of prostate cancer. And every good primary care practitioner and physician assistant at such a practice should have been aware of this by 2008 and 2009.

  6. Underlying this is the basic fact that PSA is such a lousy test for prostate cancer. It is lousy because there is no cutoff that simultaneously detects more cancer while preventing more unnecessary biopsies.

    In the latest NCCN Early detection guidelines (Version 2.2015), they advocate a standard similar to the present study. Men aged 45 to 75 years of age with PSA levels ≥ 1 ng/ml but < 3 ng/ml are advised to have repeat testing at 1- to 2-year intervals. Men with PSA levels of 3 ng/ml or higher are advised to have a repeat PSA and a DRE and a workup to determine confounding but benign sources of PSA (e.g., BPH, prostatitis, urinary retention, recent sex, or bike riding). If suspicion remains, they are advised to have either a TRUS-guided biopsy, another PSA/DRE in 6 to 12 months, or further blood work (%free PSA, phi or 4KScore).

    If doctors followed this protocol rigorously, I think it would prevent a lot of unnecessary biopsies while detecting more significant cancer.

  7. Not trying to be facetious, if two PSA tests are better than one, wouldn’t a third PSA test add to the decision making (unless the first two tests are close)?

  8. Under certain circumstances, that might be the case … but please remember that the PSA test is not specific for prostate cancer, so there is also the “What are you actually learning?” factor.

  9. My sympathy goes out to Mrs. Bishop.

    I had similar PSA values but, fortunately, my primary care physician referred me to a urologist and, as a result, I am alive today. My PSA was 2.0 in 2001 and had risen to 3.3 ng/ml 16 months later in 2002. My primary care physician referred me to a urologist who had the PSA test repeated a month later. When the results came back as 3.5, I had a prostate biopsy scheduled and the results showed a tumor with a Gleason score of 6. After consultations with my urologist, reading a lot of reference material and many discussions with my wife, I had my prostate removed in December of 2002 and everyone was very surprised when the post-op Gleason score was 9 (4 + 5), which indicated a very aggressive tumor. I had to have salvage radiation treatments in 2010 and my PSA is still non-zero (it was 0.4 in October of 2014),

    It is very likely that my prostate cancer was caused by exposure to Agent Orange during two tours in Vietnam as I do not have a family history of prostate cancer, but I am alive and functioning very well 13 years after my surgery (and 6 years after my radiation treatments). My doctor’s referral to a urologist saved my life. I am very sorry that did not occur for Mrs. Bishop.

  10. Dear Mr. Pfeiff,

    Thank you for your feedback. I agree with all of your comments, and you are right in the fact both you and Ray had similar circumstances. I talked with several medical malpractice lawyers to see if there was a case to bring before a judge. The answer I did not want to hear was: statute of limitations. In my state, Georgia, there is a 2 year statute of limitations law. I could go back even further than I told in my first story. “Red flags” could have been noticed as far back as 2006. One lawyer said there was an exception to the Georgia law of 2 years. It could be used up to 5 years back, but as luck has it, the lawyer said our 5 years would have been up in 2014. How can a medical practice withhold appropriate tests which could have saved my husband’s life without having grounds for a malpractice case, regardless of how long ago the situation occurred? Couldn’t the date of Ray’s death been the starting point because that was the end result? What I don’t understand is what problem would it have been to repeat the PSA test a month later? In my mind, I keep thinking, “They just didn’t want to take the time to do it. What harm would there have been to repeat the test? Was it too inconvenient? I’m recalling more and more, and now I remember that I asked the doctor straight forward why he didn’t refer Ray to a Urologist from the beginning? He replied, “We can’t send every man who has a slight elevation to Urologists. We’d be sending them all the time.”

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