Missed Diagnosis of Prostate Cancer With Normal Range PSA Value

This case involves a seventy-eight-year-old man who presented to a urologist with complaints of onset urinary retention, back pain, and visible blood in the urine. The physician sent the patient for blood work to determine a baseline PSA value that came back at a level of 3.0. The doctor advised his patient that given his age and relatively low PSA value, he didn’t think there was a major concern and that the patient should follow up in six months. Four months later, the patient sustained a trip and fall injury that uncovered a diagnosis of pathologic fractures to three vertebrae from bony metastasis. He was subsequently diagnosed with impending paralysis due to spinal cord compression and was bound to a wheelchair with a poor overall prognosis from the spread of prostate cancer.

Question(s) For Expert Witness

  • What is the diagnostic value of the PSA test?

Expert Witness Response E-000182

When PSA testing was first developed, the upper limit of normal for PSA was thought to be 4 ng/mL. Subsequent studies, however, have shown that no PSA level guarantees the absence of prostate cancer. As the PSA level increases, so does the risk of this disease. When the PSA is 1 ng/mL, cancer can be detected in about 8% of men if a biopsy is performed. With a PSA level of 4-10 ng/mL, the likelihood of finding prostate cancer is about 25%; with a level above 10 ng/mL, the likelihood is much higher. Although cancer may be present even when the PSA level is less than 1 ng/mL, experts do not recommend a biopsy unless the PSA is higher. Some use 2.5 ng/mL as the cutoff, while others wait until it is 3 ng/mL or greater.

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