View this summary online at guidelines.co.uk/252826.article.

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Overview

This Prostate Cancer Risk Management Programme (PCRMP) guidance helps GPs give clear and balanced information to asymptomatic men who ask about prostate specific antigen (PSA) testing. The PSA test is available free to any well man aged 50 and over who requests it.

GPs should use their clinical judgement and National Institute for Health and Care Excellence (NICE) guidance to manage symptomatic men and those aged under 50 who are considered to be at higher risk for prostate cancer

1. Prostate cancer

  • Each year in the UK about 47,600 men are diagnosed with prostate cancer and about 11,600 die from the disease. The most common age of diagnosis is 65 to 69 years
  • Men are at higher risk if they:
    • are aged 50 or older, as risk increases with age
    • have a close relative, for example brother or father, who has had prostate cancer
    • are of black ethnic origin—lifetime risk 1 in 4 compared to 1 in 8 for white men
  • Slow-growing tumours are common and may not cause any symptoms or shorten life. Some tested men may therefore face unnecessary diagnosis (overdiagnosis) of prostate cancer as well as associated anxiety, medical tests and treatments with side effects.

2. PSA test

  • The test aims to detect localised prostate cancer when treatment can be offered that may cure cancer or extend life. It is not usually recommended for asymptomatic men with less than 10 years' life expectancy
  • Most men will have a PSA level less than 3ng/ml. About 3 in 4 men with a raised PSA level (≥3ng/ml) will not have cancer. Around 15% of men with a normal PSA do have cancer
  • Before a PSA test men should not have:
    • an active urinary infection or within previous 6 weeks
    • ejaculated in previous 48 hours
    • exercised vigorously, for example cycling in previous 48 hours
    • had a urological intervention such as prostate biopsy in previous 6 weeks
  • When taking blood for PSA testing:
    • ensure the specimen will reach laboratory in time for the serum to be separated within 16 hours
    • send samples to an ISO accredited laboratory
    • repeat the test if not taken in ideal circumstances
  • A PSA test will not distinguish between aggressive tumours (which are at an early stage but will develop quickly) and those which are not. Further tests may provide valuable information
  • If the PSA is over 3ng/ml, the GP is advised to refer.

Algorithm 1: PSA testing and prostate cancer patient pathway

PSA testing and prostate cancer patient pathway

3. Digital rectal examination (DRE)

  • DRE allows assessment of the prostate for signs of prostate cancer (a hard gland, sometimes with palpable nodules) or benign enlargement (smooth, firm, enlarged gland). A gland that feels normal does not exclude a tumour
  • NICE guidance suggests that the following investigations and treatments will be part of the onward diagnosis and management of your patient.

4. Multiparametric MRI (mpMRI)

  • Pre-biopsy mpMRI of the prostate gland aims to accurately locate clinically significant prostate cancer and facilitate targeted biopsy. Studies show by using mpMRI prostate biopsy can be avoided by more than 25% of men and may reduce detection of clinically insignificant cancers.

5. Biopsy

  • A biopsy can diagnose prostate cancer and provide useful prognostic information
  • Most men experience blood in urine and semen after biopsy. About 2 out of 5 men describe biopsy as painful. The most common complications are bleeding and infections including a small risk of sepsis
  • Neither mpMRI or biopsy will detect all prostate cancers.

6. Management and treatment

  • Treatment and management options for localised prostate cancer are:
    • active surveillance
    • radical prostatectomy (open, laparoscopic or robotically assisted laparoscopic)
    • targeted and external beam radiotherapy (EBRT)
    • brachytherapy (low and high dose rate)
    • watchful waiting
    • hormone therapy
  • The options available depend on the stage of disease, the man’s age and general health. Surgery and radiotherapy may offer the possibility of a cure but can have significant side-effects. In this context it is important for men considering the PSA test to understand the effects that treatments may have on their quality of life.

7. Information for well men aged 50 and over

PSA level algorithm

  • You can direct patients to the information sheet for well men aged 50 and over for a summary of the potential benefits and risks of PSA testing
  • The information sheet for well men includes the above infographic, which explains the PSA test. It also includes a list of the potential advantages and disadvantages of the PSA test for men to consider when making a decision

Public Health England (PHE) created this information on behalf of the NHS.

© Crown copyright 2020 Public Health England. PHE PSA prostate cancer test guideline. Available from: www.gov.uk/government/publications/prostate-specific-antigen-testing-explanation-and-implementation

Contains public sector information licensed under the Open Government Licence v3.0.

First published: January 2009.

Last updated: 20 January 2020.