Synopsis
Interpret PSA in context, use pre-biopsy multiparametric MRI and risk-adapted biopsy, distinguish localised from metastatic disease and sequence surveillance, local treatment and systemic androgen-axis therapy while protecting bone and metabolic health.
- Asymptomatic PSA abnormality is a pivotal clue in Prostate cancer: Many localised cancers are detected after informed PSA testing rather than symptoms and require risk estimation rather than automatic treatment.
- Immediate priority in unstable Prostate cancer: Activate the MSCC pathway for spinal symptoms, catheterise and treat infection or renal obstruction when safe, involve urology urgently and do not delay emergency care while obtaining an elective PSA or biopsy.
- PSA with informed discussion is used early to estimate cancer probability while explaining false positives, overdiagnosis and consequences of further tests. Interpret against age, prostate volume, trend, examination, infection, ejaculation and instrumentation; repeat a moderately raised result under appropriate conditions when safe.
Key red flags
New back pain, leg weakness, sensory change or sphincter dysfunction suggests metastatic spinal cord compression.
Weakness, gait change, sensory level or bladder dysfunction with back pain is suspected MSCC and requires emergency imaging.
Investigation priorities
Estimate cancer probability while explaining false positives, overdiagnosis and consequences of further tests.
Management branches
PSA, examination, symptoms or incidental imaging creates a clinically meaningful possibility of prostate cancer.
- Discuss PSA limitations, exclude or treat infection and repeat a moderately raised result when appropriate, using life expectancy and preferences in referral decisions.
- Obtain pre-biopsy multiparametric MRI and review PSA density, lesion score, examination and family or inherited risk.
Key medicines
DegarelixGive 240 mg by subcutaneous injection as two 120 mg injections for the loading dose, then 80 mg subcutaneously every month with the first maintenance dose one month later.
Abiraterone with corticosteroidGive abiraterone 1,000 mg orally once daily on an empty stomach. In metastatic hormone-sensitive disease use prednisolone 5 mg once daily; in metastatic castration-resistant disease the licensed regimen uses prednisolone 10 mg daily.