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.