Dela
For the PSA video:
· https://youtu.be/64vGSs6WLws
For the NICE management of male LUTS video:
· https://youtu.be/fgQcv01YJg0
My name is Fernando Florido, and I am a General Practitioner in the United Kingdom. In this episode, I review the latest guidance on PSA testing as outlined in the PSA Consensus 2024, available through Prostate Cancer UK and also featured in the British Journal of General Practice. I will also discuss recommendations from Public Health England, along with key aspects of the NICE guidelines on prostate cancer (NG12 and NG131) and the Pan London urology cancer referral pathways. You can find links to all of these resources below.
Please note that the content on this channel reflects my professional interpretation/summary of the guidance and that I am in no way affiliated with, employed by or funded/sponsored by any of the institutions.
I am not giving medical advice; this video is intended for health care professionals; it is only my summary and my interpretation of the information consulted. You must always use your clinical judgement.
There is a podcast version of this and other videos that you can access here:
Primary Care guidelines podcast:
· Redcircle: https://redcircle.com/shows/primary-care-guidelines
· Spotify: https://open.spotify.com/show/5BmqS0Ol16oQ7Kr1WYzupK
· Apple podcasts: https://podcasts.apple.com/gb/podcast/primary-care-guidelines/id1608821148
There is a YouTube version of this and other videos that you can access here:
· The Practical GP YouTube Channel:
https://youtube.com/@practicalgp?si=ecJGF5QCuMLQ6hrk
The resources consulted can be found here:
Guidance updated on PSA testing for prostate cancer by Public Health England can be found here:
· https://phescreening.blog.gov.uk/2020/01/20/psa-testing-guidance/
The PSA Consensus 2024 for health professionals available in Prostate Cancer UK can be found here:
· https://prostatecanceruk.org/for-health-professionals/guidelines/psa-consensus-2024
The article published in the British Journal of General Practice: “Optimising the use of the prostate- specific antigen blood test in asymptomatic men for early prostate cancer detection in primary care: report from a UK clinical consensus” can be found here:
· https://bjgp.org/content/74/745/e534
The leaflet on PSA testing and prostate cancer advice for men without symptoms of prostate disease aged 50 and over can be found here:
The NICE guideline on prostate cancer: diagnosis and management [NG131] can be found here:
· https://www.nice.org.uk/guidance/ng131
The NICE guideline on Suspected cancer: recognition and referral [NG12] can be found here:
The Pan-London suspected cancer referral forms can be found here:
The information leaflet recommended by Public Health England for well men aged 50 and over containing a summary of the potential benefits and risks of PSA can be found here:
· https://www.gov.uk/government/publications/prostate-specific-antigen-testing-description-in-brief
The NICE management of male LUTS video:
· https://youtu.be/fgQcv01YJg0
Intro / outro music: Track: Halfway Through — Broke In Summer [Audio Library Release]
- Music provided by Audio Library Plus
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Transcript
If you're listening to this podcast on YouTube, for a better experience, switch to the video version. The link is in the top right corner of the video and in the episode description.
Hello and welcome, I’m Fernando, a GP in the UK. Today, we’ll look at the latest guidance on PSA testing, as outlined in the PSA Consensus 2024, available through Prostate Cancer UK and also featured in the British Journal of General Practice. We’ll also cover recommendations from Public Health England, some aspects of the NICE guidelines on prostate cancer (NG12 and NG131), and the Pan London urology cancer referral pathways, focusing on what is relevant in Primary Care only. You can find links to all of these in the episode description.
If you’d like a refresher on the NICE guidance for managing male LUTS, please refer to the corresponding episode on this channel. The link is also in the episode description.
Right, let’s jump into it.
Although the PSA Consensus 2024 focuses on PSA testing in asymptomatic men, we’ll also cover testing in symptomatic patients.
So let’s start with patients with symptoms.
While many people with prostate cancer are asymptomatic, we should suspect it if there are unexplained symptoms. Possible prostate cancer symptoms can be non-specific, such as:
- Anorexia or weight loss,
- Lethargy, or
- Lower back or bone pain.
or urological symptoms, such as:
- Erectile dysfunction,
- haematuria, or
- Any lower urinary tract symptoms (LUTS), including nocturia, urinary frequency, hesitancy, urgency, or retention.
Even though male LUTS alone do not necessarily suggest prostate cancer or automatically warrant PSA testing, the NICE cancer guideline (NG12) recommends checking PSA and performing a digital rectal examination when these symptoms are present or whenever there’s any suspicion of prostate cancer.
We will make an urgent referral on the cancer pathway if a DRE reveals a suspicious prostate or PSA levels exceed age-specific thresholds. These thresholds are:
- 40–49: above 2.5 ng/mL
- 50–59: above 3.5 ng/mL
- 60–69: above 4.5 ng/mL
- 70–79: above 6.5 ng/mL
- For those aged under 40 or over 79, we will use our clinical judgement.
In addition, the Pan London cancer referral pathway states that the raised PSA should be in the absence of a UTI, or when the PSA levels remain elevated at least 8 weeks after a UTI has been treated. On the other hand, if the PSA exceeds 20 ng/mL, an urgent cancer referral can be made even if a UTI is present.
Right, so, we've covered what to do for symptomatic patients. Now, let’s look at the recommendations for PSA testing in asymptomatic patients.
Currently in the UK, PSA testing is freely available to anyone aged 50 and over who requests it. This includes anyone with a prostate, including trans women and non-binary people. Patients who request the PSA test should receive balanced information on the pros and cons of testing. Public Health England recommends a patient information leaflet, outlining the potential benefits and risks of PSA testing. A link to this leaflet is available in the episode description.
However, Public Health England also advises that GPs should not proactively raise the topic of PSA testing with asymptomatic people. This is due to the potential harms of overdiagnosis and overtreatment of slow-growing prostate cancers, which are common and may not cause symptoms or shorten life expectancy.
Additionally, PSA is not a perfect test. Although most patients have a PSA level below 3 ng/mL, around 75% of men with a PSA above this threshold do not have cancer. On the other hand, about 15% of men with a low PSA will later be found to have prostate cancer.
PSA levels can also be elevated for various reasons other than prostate cancer, including UTIs, benign prostatic hyperplasia, prostatitis, as well as recent ejaculation or vigorous exercise.
Therefore, before performing a PSA test, we should ensure the patient does not have:
- A UTI, or has not had one within the last 6 weeks,
- That they have not ejaculated or engaged in vigorous exercise within the past 48 hours, or
- That they have not undergone any urological interventions in the past 6 weeks.
We should also consider that medications like finasteride, can also increase PSA levels.
Now that we’ve reviewed the current recommendations, let’s look at the new guidance in the PSA Consensus 2024. This consensus was developed because current testing guidelines are based on an outdated diagnostic pathway, where a biopsy typically followed a raised PSA. The current pathways are more accurate, using MRIs and thus reducing the risk of overtreatment. Moreover, existing guidelines do not offer clear advice for men who are at higher risk of prostate cancer.
Another reason was to address potential health inequalities. While PSA tests are freely available through the NHS, GPs are instructed not to proactively raise the issue, meaning that the more health-literate and affluent patients are more likely to request testing, leaving men in deprived areas with lower testing rates.
Whilst the consensus still recommends that asymptomatic men should be provided with balanced information on PSA testing and should have access to it starting at age 50, in order to address all these concerns, it also recommends a more proactive approach for men who are at higher risk of prostate cancer, even though it does not go as far as recommending general screening.
Therefore, the consensus states that we should proactively discuss prostate cancer risk and PSA testing with those at higher risk, which includes:
- Black men aged 45 and over (as Black ethnicity alone confers a higher risk),
- Men aged 45 and over with a family history of prostate cancer, and
- Men with confirmed genetic risk factors, such as a BRCA2 gene variation.
The responsibility for raising awareness about prostate cancer in primary care lies with all trained healthcare professionals, not just GPs, and patients should still be provided with balanced information on PSA testing.
There was no consensus on PSA threshold values for asymptomatic patients due to insufficient evidence for age-specific thresholds. Currently, the referral threshold for asymptomatic men is a PSA level of 3.0 ng/mL or higher.
However, questions were raised regarding the rationale behind this threshold, especially for men aged 50–79. Let’s remember that, for symptomatic patients, NICE recommends different thresholds based on age: 3.5 ng/mL for those in their 50s, 4.5 ng/mL for those in their 60s, and 6.5 ng/mL for those in their 70s. Concerns were raised that using the lower threshold of 3.0 ng/mL in asymptomatic patients could lead to overtreatment. However, since no alternative thresholds were agreed upon, we will have to use our clinical judgement in order to decide whether to investigate further or refer.
Also, while DRE is still valuable in symptomatic patients, there is uncertainty over its usefulness in asymptomatic people so, if a referral is needed because of a high PSA, a DRE prior to referral was not strictly necessary especially evidence suggests that DRE can act as a barrier for some men seeking help. This is also the case in patients with normal PSA levels, even when risk factors like family history or Black ethnicity are present. The low positive predictive value of DRE and inconsistent results between primary and secondary care were cited as concerns. However, if a DRE is performed and the findings are suspicious, referral should then be made, even with a low PSA.
There was no agreement on whether DRE prior to testing increases PSA levels, so its impact on PSA results remains uncertain.
The frequency of repeat PSA testing should be based on individual risk factors. There was no consensus on specific intervals for repeat testing due to insufficient evidence and concerns about the burden on primary care. However, it’s likely that PSA testing will be required at least annually, potentially more often for high-risk patients or those with fluctuating PSA levels.
There is also a role for the use of PSA velocity in determining whether to refer to secondary care, but again, no specific guidance was given about this.
What is PSA velocity?
PSA velocity refers to how quickly the PSA increases over time. A rapid increase in PSA (even if the total PSA level is not very high) can be an indicator of an underlying prostate issue.
A PSA velocity of more than 0.75 ng/ml per year has been used as a threshold in some clinical settings to prompt further investigation. So, although PSA velocity is not officially incorporated into NICE guidance for asymptomatic patients, it can still be considered if there are concerns, always taking into account that PSA velocity has limitations, so it should always be interpreted in the context of the overall clinical picture.
Although there was no consensus on broader screening for asymptomatic patients due to the risk of overdiagnosis and overtreatment, there is agreement on the following points:
- The PSA blood test is the first step in the prostate cancer diagnostic pathway, identifying men who may benefit from further testing, typically an MRI and
- The balance of benefits and harms is shifting in favour of screening, but further research is still needed.
In summary, current guidelines recommend that GPs do not proactively raise the issue of PSA testing with asymptomatic men. However, the PSA Consensus 2024 challenges this, advising primary care professionals to have proactive discussions with men aged 45 and over who are at higher-than-average risk, including those of Black ethnicity, with a family history of prostate cancer, or with genetic risk factors. However, it did not recommend proactive conversations for all at-risk men — that is, aged ≥50 years without other risk factors.
This consensus reflects changes in policy in other countries. For example, EU member states are considering stepwise implementation of organised prostate cancer screening programmes, and a U.S. expert panel recently recommended annual PSA screening for Black men starting at age 40.
This shift is likely to prompt a review of UK guidelines in the near future.
And that is it, a review of PSA testing for early prostate cancer detection in primary care.
As always, remember that this is not medical advice, but only my summary and my interpretation of the guidelines. You must always use your clinical judgement.
Thank you for listening and goodbye.
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