All about

PSA !!!
Dr. Lim Li Yi
Urology Specialist
Hospital Kuala Lumpur
 What is PSA
• Glycoprotein
• Secreted by prostatic ductal epithelial cells
• liquefy the seminal coagulum within the
ejaculate
• PSA exist in free and bound forms
• Prostate specific but not prostate cancer
specific
• Causes of raised PSA
• Malignancy
• BPH
• Urinary retention
• Infection
• Inflammation
• Instrumentation / catheterisation
When to take PSA?

PCa
Diagnosis
Screening
Red flags for advanced PCa
• Bone pain
• Acute neurological symptoms
• Renal failure
• Hematuria (without UTI)
Who need PSA for screening?
Important points for counselling
• Increased diagnosis of PCa
• Detection of more localized disease and less advanced PCa

• ? PCa specific survival benefit

• Any reduction in mortality may take up to 10 years to accrue
• Men with life expectancy <10-15 years unlikely to be beneficial

• Overtreatment and treatment related harms

• Impact on QoL
What is normal PSA
• No PSA cut-off that completely predicts the absence of PCa
• Continuous parameter, higher levels, greater likelihood
• Balance tradeoffs between sensitivity and specificity, and
avoids subjecting men to unnecessary biopsies

PSA ≥4ng/ml
Most widely
accepted standard
• Correction for 5 alpha reductase inhibitors
• Finasteride & dutasteride
• Procedure ≥50% reduction in PSA after 3-6 months
• Reduction of prostate volume
• Interference with prostatic intracellular androgen response mechanism
• establishing a new baseline 6 months after
• any rise from new baseline - higher risk of PCa or higher-grade Pca - refer
• PSA × 2 for 1st 2 years, × 2.5 on long term use
Improving specificity of PSA
1. Free/Total PSA
• No clinical use if total serum PSA >10ng/mL
• Men with PSA 4-10ng/ml

F/T PSA % PCa

<0.1 56%

>0.25 8%
2. PSA Density
• Serum PSA divided by prostate volume
• Higher the PSA density, more likely PCa is clinically significant
• PSAD of >0.15 ng/mL/mL is more likely to diagnose with PCa
Prostate cancer calculator
PCPT Cohort ERSPC Cohort

http://www.prostatecancer-riskcalculator.com/seven-
https://riskcalc.org/PCPTRC/ prostate-cancer-risk-calculators
When to refer to Urology?

PSA ≥ 4ng/mL
Rise in PSA while on 5-alpha reductase inhibitor
Abnormal DRE
Red flag symptoms (urgent)
What’s next for patients?
• Assessment
• mpMRI of prostate (kiv)
• Prostate biopsy
• Commonly transrectal ultrasound guided
• Office procedure
• Risk: bleeding, infection
Common questions
Raised PSA, need to repeat?
• PSA should be taken under standardised conditions:
• No ejaculation
• No manipulation
• No UTI
• Limited PSA elevation should be verified after few weeks - same lab and assay
• Empiric use of antibiotics in asymptomatic patient in order to lower PSA
should not be undertaken
 Can take PSA after DRE?
• YES
• DRE - insignificant changes in PSA
• Transient elevation of 0.26-0.4ng/mL 1 2

1. Effect of digital rectal examination on serum prostate-specific antigen in a primary care setting. The Internal Medicine Clinic
Research Consortium. Arch Intern Med 1995; 155:389.
2. Chybowski FM, Bergstralh EJ, Oesterling JE. The effect of digital rectal examination on the serum prostate specific antigen
concentration: results of a randomized study. J Urol 1992; 148:83
Can take PSA at time of AUR?
• NO
• PSA raised during AUR - ? secondary to prostatic infarction
• a delay of 2 weeks - half-life of PSA is 2-3 days.
When to stop screening
• up to 70 years, or 75 years if patient desires
• Study found screening survival benefit only among men 55-69 years
• Aggressive treatment of PCa in men age >70 years would decrease QoL