What to do with abnormal PSA results in a young man

A 45-year-old man in excellent health with no family history of prostate cancer had a screening PSA done three years ago which was in the range of 4.0 ng/mL. He has been followed by a urologist, and the test was repeated several times without much change.

In June of this year, his PSA was 4.6 and the free PSA was 0.6 for a ratio of 0.13. He was given a course of antibiotics for presumed prostatitis, and repeat testing a month later showed a PSA of 3.8 with a free PSA of 0.5. Because the PSA was less than 4, a ratio was not calculated.

The patient obtained copies of the reports. The from June one states the following: "When total PSA is in the range of 4.0-10.0 ng/mL, a free PSA/total PSA ratio of less than or equal to 0.10 indicates a 49% to 65% risk of prostate cancer depending on age. A free PSA/total PSA ratio of greater than 0.25 indicates a 9% to 16% risk of prostate cancer depending on age." It does not comment on the significance of a ratio of 0.13, which I have looked up. The cancer risk is in the area of 20%-25%. However, no source gave estimates for men under the age of 50.

On examination, his urologist can feel no nodules. He has recommended that the patient undergo an MRI of the prostate.

Stating that an MRI is not indicated in a man of his age with his history, the patients insurance company will not pay for the test and suggested a trans-rectal ultrasound. The urologist advised the patient not to have an ultrasound due to his age and the potential for complications. A hospital quoted him an out-of-pocket price of $2500 for the MRI.

The urologist has told him that random biopsies may not be accurate and there is a risk of complications.

When he had his first PSA done three years ago, I had expressed surprise and wondered why it had been offered to him. The patient said his internist told him he should have the test.

He is concerned about these recent results and has asked me for advice which I am not qualified to give.

What would you advise?

Follow-up August 6, 2014

Numerous urologists responded on Twitter with more than 60 tweets about this post. Suggestions for the next step were as follows: trans-rectal ultrasound (TRUS) and biopsy as mentioned by Dr. Cooperberg below; going ahead with the MRI; repeating the PSA in 3 months; go for a second opinion by a recognized expert in prostate cancer.

One urologist emailed me to point out that even if the patient has cancer, it is probably not an aggressive type because his PSA has not risen in 3 years.

Another urologist gave me the name of an expert in the patients geographic area. 

The patient has already scheduled an appointment for a second opinion.

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Improving the M M conference

"Surgical pathology works more than 80 hours per week, has no regard for your gender or your life situation, and can be devious and sneaky in its presentation."

The following is a guest post by Dr. Leo Gordon, a surgeon from Los Angeles.

A recent paper in Annals of Surgery found that 24% of graduating surgical residents "were unable to recognize early signs of complications." One possible solution is a redesign of the morbidity and mortality (M&M) conference .

I have spent a significant part of my professional life in an effort—at this point it is a crusade—to change the nature of the M&M conference. For 11 years, I moderated 495 conferences, 1485 presentations, and 30 written examinations based on the error and complication-reducing points raised during the discussions.

If properly implemented, a redesigned M&M conference can satisfy the ACGME core competencies, the suggestions of the Institute of Medicine, and the publics demand for a reduction in medical errors.

What I have dubbed the "M&M Matrix" converts the weekly conference into a vibrant educational effort and creates a constantly updated patient safety curriculum for the resident and attending staff.

If the M&M Matrix is such a valuable idea, why hasn’t it been widely adopted?

Here are the reasons:

1. Implementing the M&M Matrix is a ton of work.

Setting up this program and changing the culture of a traditional conference requires acceptance at all levels of the department. It is a week-long effort, not a one-shot Tuesday morning flirtation with surgical education. To pull this off, someone is going to have to be paid, which is a stumbling block. The residents have to buy into this program. It is more work for them, but think of the benefits of the cautious analysis of a complication. Most departments look at the concept, realize how much work it will take, and revert to the traditional conference.

2. The M&M Matrix requires a moderator with specific talents.

Effective moderation of this conference requires a certain set of skills that not every attending surgeon possesses. The moderator has to select educationally valuable complications to discuss. The moderator has to…well…moderate the conference, focus on worthwhile comments, recognize the difference between a legitimate statement and the sweet reverie of surgical anecdote, and do it in a respectful manner. The moderator has to summarize the conference in a HIPAA compliant manner, distribute the teaching points, and construct an examination based on the conference.

3. The M&M Matrix relies on a structure of classic surgical education, a structure suffering advanced erosion.

I am entering my 36th year of practice. My view of surgical education is inconsistent with work-hour restrictions, life-style considerations, hand-offs, and current methods of patient care. I view the discipline of surgery as an effort to eradicate surgical pathology. Surgical pathology works more than 80 hours per week, has no regard for your gender or your life situation and can be devious and sneaky in its presentation. The method of assessing the effects of surgical pathology should be just as rigorous. I hate to fall back on a military analogy, but the M&M conference should be a boot-camp or basic training for the real war.

4. There is no statistical proof that the M&M Matrix decreases the incidence of complications.

The academics and statisticians have got me here!

How do you get inside the head of a senior resident as he is digging out the left colon in a tough diverticulitis case and show that in that fecund mind, because of this educational format, the resident is thinking:

"Gee, we discussed a lacerated ureter a few months ago. Remember the techniques of assessing the ureter that we discussed at the Matrix Conference? Didnt the outline we got and the test questions suggest that we should identify the ureter above and below and make sure we stay close to the colon?"

How does one quantify that a complication was avoided because of an educational effort?

These four reasons for lack of wider adoption can be overcome by a thoughtful analysis of the benefits of a redesigned conference. Given the current problems confronting surgical education, I believe that the idea will be re-evaluated and will eventually be adopted.

Time will be increasingly valuable in upcoming 60-hour work week. The hour allotted for the analysis of surgical complications has to be leveraged into a durable learning experience.

The incoming president of the American College of Surgeons, Dr. Andrew Warshaw, has chosen Dr. Ernest Codman as the subject of his presidential address. Dr. Codman invented the M&M conference. He conceived and implemented it, and in so doing improved surgical care. I hope that Dr. Warshaw’s remarks will spark a renewed interest in a re-design of the M&M conference.

I have a viable plan. Now I need the support to implement this plan. Perhaps I can complete Dr. Codman’s work!

If you have an opinion about the M&M Matrix, please comment below or contact the author—LeoGordonMD at gmail.com

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