Guidance for referring patients for suspected prostate cancer

• GPs should continue to refer men with suspected prostate cancer on the urgent suspected urological cancer form
• GPs should undertake prostate-specific antigen (PSA) testing in symptomatic patients in line with NICE guidelines (new lower urinary tract symptoms, visible haematuria, unexplained non-visible haematuria with dysuria or raised WCC on blood test)
• GPs should continue to undertake PSA testing in asymptomatic patients following GIRFT guidelines. 

PSA test guidelines 

• Routine PSA testing is not offered on the NHS. 
• Anyone aged 50+ with a prostate can ask their GP for a PSA test, even if they do not have symptoms.
• The age requirement should be lowered to 45 for those with black or mixed black heritage and/or those with a family history of prostate and/or breast cancer.

Consider opportunistic testing following the guidance in a letter from NCL clinical leads.

• Those at a higher risk can have a PSA test after discussion of prostate cancer risk.
• When the PSA is raised, use a urine test to exclude infection.
• No digital rectal examination is needed if the PSA is raised.
• If DRE has been done, and is abnormal, refer to secondary care on an urgent suspected cancer pathway, even if the PSA is within normal limits.
• There is no need to repeat a raised PSA unless there are other probable causes of a raised PSA, for example a urinary tract infection or recent catheterisation.
• Patients with a PSA > 20ng/ml should always be referred using an urgent suspected cancer pathway regardless of other potential causes.
• Do not routinely test PSA in asymptomatic patients aged 80+ or co-morbid patients
• There is a risk that a PSA test result may not be accurate.

Making an urgent suspected cancer referral

If GPs make an urgent suspected cancer referral they are asked to:

• take the opportunity to discuss the need for men to attend secondary care for their investigations and to address/reassure them regarding any concerns they may have
• include any previous PSA results in the referral, as PSA trajectory is useful clinical information
• ensure that an estimated glomerular filtration rate (eGFR) result from the last three months is included
• please note: if a PSA or eGFR  result is not included, some local trusts, such as University College London Hospitals  and North Middlesex University Hospital, will perform the tests, even with a report of an abnormal DRE. This delays access to a multiparametric MRI (MpMRI) until results are available, and therefore bypassing the test in primary care will not hasten secondary care appointments
• GP should share this film link with patients: What to expect from your prostate clinic referral.

Further primary care prostate guidance from Getting It Right First Time (GIRFT) can be found on page 6 of the document GIRFT Urology: towards better diagnosis & management of suspected prostate cancer.

Advice on PSA testing in the over-80s can be found on the Academy of Medical Royal Colleges website.

How to Refer