After the PSA Cutoff Era: The Importance of Context
About two years ago, having recognized that the prostate-specific antigen (PSA) cutoff level of 4.0 ng/mL did not always assist in accurately categorizing a man's risk for prostate cancer, we began to eliminate this—or any—artificial cutoff defining a “normal” PSA value.
Relying on amassing data and referencing key series, we included on all PSA reports an explanation that the PSA level should be considered along with several other factors when making a decision regarding urological evaluation or prostate biopsy.
We anticipated with concern that changing the way we reported PSA would increase anxiety if men or referring physicians saw that for any given PSA level, there is a defined risk of undiagnosed cancer. We also were concerned that the number of referrals and prostate biopsies might increase inappropriately, so we tracked this carefully. Ironically, once we stopped flagging PSA values, we identified a severe drop-off in referrals for elevated PSA.
The intent of this initiative was to accurately report PSA values with a meaningful
interpretation of their implication rather than reporting a number that was a relatively meaningless cutoff without context. The drop-off in referrals raised concern that perhaps high levels were going unnoticed when reported in this way. Thus, we have begun to again flag reports for PSAs over 4.0 for the benefit of the primary-care physician (PCP). We do include verbiage that this does not define abnormality but rather that it needed to be brought to the physician's attention.
We are now tracking referral patterns related to drawing attention to reports with abnormal PSA levels. Our hope is that we will encourage the PCP to closely examine results in the context of a broad range of factors, including patient medical history and previous clinical tests, and to improve decision-making compared with simply reporting abnormal PSA values.