A 64-Year-Old Man with Elevated PSA Levels - Episode 1
Judd W. Moul, MD, FACS, introduces the patient profile and discusses typical characteristics of patients undergoing prostate cancer screening in his practice.
Patient Case: A 64-Year-Old Man with Elevated PSA Levels
Judd W. Moul, MD, FACS: Hi, I am Dr Judd Moul. I am a urologist at the Duke Cancer Institute in Durham, North Carolina. My practice focuses on prostate cancer and prostate disease, and I am delighted today to present an interesting case that we all see in practice. This is a 64-year-old man who underwent PSA [prostate-specific antigen] testing during his annual physical with his primary care physician. His PSA was 5.6 [ng/mL], and his PSA density was 0.16 [ng/mL2]. He then saw a urologist who ordered a multiparametric MRI, and the result showed a PI-RADS [Prostate Imaging Reporting and Data System] score of 4 lesion. 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 the risk of prostate cancer. And his test score was 16.3, with the upper limit of normal being 15.6, so he had a just slightly elevated exosomal test. The patient’s urologist remained concerned about the PI-RADS 4 lesion on the MRI. The urologist also noted that his PSA density was slightly abnormal at 0.16 [ng/mL2]. At that point with all the data, the patient elected to undergo a TRUS [transrectal ultrasound]-guided biopsy, which actually was negative for prostate cancer.
This is a really common situation. For example, where I work at Duke, we have an initiative where we started a program with our Duke Primary Care Network to better educate our primary care physicians on the use of the PSA test. We have a large African American and underserved population, so we felt that it was necessary to do that. This scenario happens all the time, a middle-aged gentleman who has borderline testing. We are dealing with men, and men in general don’t go to the doctor as often, don’t follow our instructions as often. So a scenario like this where the guy gets an abnormal test result and is reluctant to undergo a biopsy is pretty much something I see every week in practice.
PSA density is the PSA divided by the prostate volume, and it’s trying to take into account what proportion of the PSA protein is coming from the enlarged prostate versus prostate cancer. A PSA density of 0.15 [ng/mL2] or less is considered a normal PSA density, and anything greater than 0.15 [ng/mL2] is considered abnormal. This patient we discussed today has a PSA density of 0.16 [ng/mL2], which is considered slightly abnormal. That means that at least a higher proportion of the time we would expect him to have prostate cancer because less of his PSA is coming from the enlargement and more of the PSA may be coming from his potential prostate cancer.
Transcript edited for clarity.