A 64-Year-Old Man with Elevated PSA Levels - Episode 3

Early Detection of Prostate Cancer: Challenges and Strategies

Judd W. Moul, MD, FACS, reviews challenges of early detection of prostate cancer, and strategies to mitigate them.

Patient Case: A 64-Year-Old Man with Elevated PSA Levels

  • A 64-year-old-man underwent PSA testing during his annual physical with his primary care physician; PSA was 5.6 ng/mL and PSA density was 0.16.
  • He then saw a urologist, who ordered a multiparametric MRI; result was PI-RADS 4.
  • The patient was reluctant to undergo a prostate fusion biopsy, therefore the patient’s urologist recommended that he undergo exosome-based molecular testing to help determine risk of prostate cancer; his test score was 16.3.
  • The patient and urologist remained concerned about his PI-RADS 4 MRI score. The urologist also noted that the PSA density of 0.16 was slightly above the threshold of 0.1.
  • The patient elected to undergo TRUS-guided biopsy, which was negative for prostate cancer.

Judd W. Moul, MD, FACS: Challenges surrounding early detection of prostate cancer are certainly several fold. No. 1, you have men themselves, and a lot of men just don’t like to visit the doctor and they don’t go to the doctor for checkups. So, right off the bat, that’s one issue. For example, if you compare men to women, women are much more likely to be compliant for breast exams and mammography, and be more proactive when they are diagnosed with breast cancer. Whereas men have been traditionally more reluctant to go to the doctor, more reluctant to have exams. Men don’t like to have a digital rectal exam if they don’t have to. But even men, again, if they are not keyed into the value of the PSA [prostate-specific antigen] test, they will never know to ask for it. Then while the PSA test is exceedingly useful, and I don’t believe it’s ever going to go away as our benchmark initial screening test, the PSA has a lot of challenges in its specificity and sensitivity, taken into a whole realm of further discussion that we are going to do.

Most patients would come to see me as an urologist after they’ve had at least a baseline PSA test. I would say about half the referrals that I get are patients who are referred from a primary care physician with a solitary elevated PSA. In this era, most primary care physicians don’t do a rectal exam, so most of the time the patient has either a mildly or significantly elevated PSA and no other testing. That’s basically about half. Then you have the other extreme that I see, the guy who is so very well informed and has had an elevated PSA, maybe has had other testing done, but is reluctant to get a prostate exam. He may be coming to me as his third urologist to counsel him on what to do for an elevated PSA. Those are the 2 extremes. Then you have everybody else in the middle, probably many guys who might have had a number of PSA tests, and they are either borderline or going up slightly. Occasionally you will get a patient from the primary care physician who has had both a PSA test and a prostate MRI. Sometimes you even get patients who have had other secondary tests beyond PSA, such as a PSA plus, for example, a Prostate Health Index test, or 4Kscore, or even an exosomal urine test.

Transcript edited for clarity.