Doctor Fails to Order Additional Testing After Elevated PSA Level is Detected

Case Overview

This case involves an elderly man who was diagnosed with prostate cancer. He had been followed for over a decade by the same physician, who began performing PSA testing. A PSA was done which revealed a PSA level that was slightly above the upper normal limit threshold of 4.0 ng/ml. There was no digital rectal exam, and the elevated PSA study was never addressed. No follow-up studies were done until the patient presented to again with severe pain during urination. The patient’s prostate was markedly enlarged, and he was diagnosed with Stage IV cancer.

Questions to the Urology expert and their responses

What are the guidelines for screening when the PSA is steadily increasing?

The basic standard of care at this time consisted of the use of PSA, DRE and/or TRUS. In addition, the use of adjunctive measures were applied to improve both sensitivity and specificity of our basic screening measures, esp. PSA. This included variant PSA measures such as PSA kinetics (PSA velocity, PSA doubling time), % free PSA, PSA density (#PSA value/volume(size) of prostate gm/cc), and biomarkers (ex urine PCA-3 test). The provider in this case failed to appreciate clinically significant PSA elevation and PSA kinetics (specifically PSA velocity) and perform a proper DRE. If physician adhered to accepted standards this would have led to further evaluation which includes biopsy and ultimately diagnosis (at earlier stage).

About the expert

This board certified urologist earned his MD and completed residency training at the University of British Columbia. He later completed a fellowship in urology at the highly regarded University of Texas MD Anderson Cancer Center. He is active as a member of the American Urologic Association, the Society of Urologic Oncology, and the Society of Urologic Robotic Surgery and has nearly 30 publications. Formerly, he worked as an assistant professor of urology at the University of Miami. This expert is currently an assistant professor of urology at a top university-affiliated medical center.

E-014220

Specialties:

Urology