What do you do for a patient with a prostate nodule? What if his PSA is reassuringly low? Should you even order a PSA in the first place?
This year, the Canadian Family Physician journal published 2015 referral guidelines on suspected prostate cancer.
Four things to know from these new guidelines:
1. Remember the 10-20 rule. That's the PSA cutoff for low, medium, and high risk for requiring nonurgent, semiurgent (10-20), and urgent (>20) referral.
2. The above rule doesn’t apply if the patient has prostate findings. All patients with hard or irregular prostate on DRE need to see a urologist; the question is how soon. For patients with prostate findings, the cutoff is 10; below that, nonurgent referral; above that, urgent referral.
3. Ask about suspicious symptoms! Red flags include:
- Low back pain, especially when reproducible by percussion
- Severe bone pain
- Weight loss
Even if their PSA is low risk (remember that’s < 10), and DRE are normal, a patient with these symptoms should be referred.
4. Think “What else could it be?” Before thinking cancer, be sure to make sure your patient’s elevated PSA isn’t due to:
- Infection i.e. Urethritis, cystitis
- Recent sexual activity
- Recent DRE (though this doesn’t increase the PSA enough to change management, so go ahead and do the DRE before the patient gets their labs done)
Note this guideline does NOT cover screening - and for that you should be very familiar with the current and controversial Canadian guidelines on prostate cancer screening using PSA, available at the CTFPHC - we’ll be sure to discuss this guideline, and review all of the 99 topics at the review course.