A 64-Year-Old Man with Elevated PSA Levels - Episode 9

Recommended Management of the Profiled Patient

An expert urologic oncologist revisits a patient profile and discusses how he would have approached the patient’s prostate cancer screening process.

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: It’s interesting, this particular patient, he did have a borderline exosomal test. And so, in general, I probably would’ve reassured him and probably would’ve not recommended a biopsy in that particular case. However, again, by the letter of the law, and if you follow the guidelines of the test the way it’s been published and the way it’s marketed, he did have an abnormal exosome test and did go on to receive a biopsy. In this case, he had a negative prostate biopsy.

His other numbers were very borderline. What I would do in practice is recommend I see him back for a repeat examination in 12 months. Now, that repeat examination would include a digital rectal exam and a repeat PSA [prostate-specific antigen test]. In my practice, I would honestly probably do a Prostate Health Index test instead of a repeat PSA because that Prostate Health Index would give me a total PSA, it would give me a free PSA, and it would give me a Prostate Health Index score. That’s solely because, at my institution, we do the Prostate Health Index blood test in house. It’s just as easy for me to get that test as a total PSA. However, if a practice doesn’t have access to that, then I think it would be very reasonable for this particular patient to simply have him come back in 12 months for a digital rectal exam and a total PSA.

If that total PSA was “about the same,” in other words, there had been no significant rise, then I probably would not have ordered a repeat MRI, and I probably would not have ordered any other repeat molecular testing, such as exosome. However, if that 1-year follow-up, certainly if the PSA was greater than 2 points higher than it was when we did the initial biopsy, then I would be more concerned that we might have missed cancer or missed high-grade cancer. And then I would be more aggressive. His PSA was, looking back, it was 5.6 [ng/mL]. Let’s just say a year later, instead of 5.6 [ng/mL], it was 7.6 [ng/mL], 2 points higher. That would be a red flag that I might have missed cancer on the first biopsy. Then I would be more aggressive with repeating the MRI, or an exosomal test, or another repeat biopsy.

Transcript edited for clarity.