PSA Counselling

Casebank Counselling
1

Who you are:
You are an FY2 doctor in GP surgery

Who your patient is:
James Parkinson, aged 55 has presented with some concerns

Other information we have about the patient:
None.

What you must do:
Talk to the patient and address his concerns

Patient information:
Opening Sentence: I want you to do a PSA for me.

  • You want to know about Prostate specific antigen
  • you normally play golf with your friends
  • your friend got prostate cancer and it spread every in his body
  • Your friend is okay but he can no longer play golf
  • You are worried that the same thing may happen may happen to you as well.
  • You do not have any symptoms
  • You are normally fit and well and not on nay medications
  • you drink alcohol occasionally

Questions:

  • What is PSA?
  • What are the chances of me getting prostate cancer?
  • If a PSA is positive, what do we do?
  • What if I’m not ready for an examination?
  • If PSA is low, does it mean there is no cancer?
  • What happens if I have prostate cancer?

Emotions and Attitude: Normal

Examiner’s prompts: No prompts.

Approach

GRIPS: Acknowledge that: yes sometimes testing with PSA may be required.

Take history

  • Can I aks you few questions to see whether a prostate specific antigen is appropriate I your case;
  • May I know how old are you?
  • Is there any particular reason why you your feel that you need a PSA blood tests?
  • Apply EVE protocol: I am sorry to hear about yout friend. Is he ok now.

Take history of prostate cancer:

  • Any back pain?
  • Any weight loss?
  • Any blood in the urine?
  • Any nocturia? Frequency? Dribbling? Hesitacy?

Risk factors of prostate cancer:

  • Sorry to ask you this question: Is there any one in your family who has ever been diagnosed with prostate cancer?
  • Do you smoke?
  • PMHx, DHx

Explanation:

  • PSA is usually offered to men aged 50 years and above.
  • PSA stands for Prostate specific antigen .
  • It is usually produced from the prostate gland both by the cancerous cells and normal cells of the prostate gland .
  • But it is not very specific , in other words the blood tests of PSA is not very specific for prostate cancer

RAISED PSA

  • If PSA is raised it may be sign that you have got prostate cancer
  • But you would still need further investigation such as MRI scan and biopsy of the prostate gland in order to confirm that.
  • Because PSA may also be raised in benign enlargement of prostate gland or infection of the prostate gland or water works infection
  • 3 out of 4 men who have raised PSA will not have cancer

NORMAL PSA

  • If PSA normal it means that you are less likely to have prostate cancer but you would still need to look out for the symptoms of cancer such as back pain, problems with urination suhc us nocturia, dribling, hesitancy.

In an unfortunate situation where you are found to have cancer

  • You will be referred to the specialist-the urologist
  • You would need further scans to see whether the cancer has spread or not
  • Treatment may include;

  1. watchful waiting
  2. operation
  3. Radiotherapy
  4. Hormonal treatment.

Benefits of PSA test

  • Early detection of cancer: finding out about prostate cancer early
  • Early treatment, if you find out early about prostate cancer you can start treatment early
  • If can offer you reassurance, but it can as well miss cancer.

Disadvantage

  • False negative: It may be normal even if you have prostate cancer . 15 out of 100 men with normal prostate cancer end up to have cancer.
  • False positive: It may be raised even you do not have cance. 75 out of 100 with high PSA do not have prostate cancer .

Advice:

  1. Perform examination of the prostate gland
  2. We perform PSA in order for you to be assured
  3. Safety netting: back pain, blood in urine, nocturia, frequency, weight loss
  4. Offer a leaflets about prostate cancer and testing with PSA
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In the scenario where a patient is undergoing prostate-specific antigen (PSA) testing and provides a family history of prostate cancer, and mentions that he has ejaculated within the last 48 hours, there are specific considerations and steps to take:

Understanding the Context:
Family History: A significant family history of prostate cancer increases the patient’s risk and underscores the importance of accurate PSA testing.
Ejaculation: Recent ejaculation can temporarily elevate PSA levels, potentially leading to a false-positive result.
Recommended Actions:
Reschedule the PSA Test:

It is advisable to reschedule the PSA test to avoid any influence of recent ejaculation. The patient should abstain from ejaculation for at least 48 hours before the test to ensure accurate results.
Document Family History:

Carefully document the family history of prostate cancer, including the ages and relationships of affected family members, as this information is crucial for risk assessment and further decision-making.
Counseling and Education:

Educate the patient on the importance of avoiding activities that can elevate PSA levels, such as ejaculation and vigorous physical activity, prior to the test.
Repeat PSA Testing:

Schedule a follow-up PSA test after ensuring the patient has abstained from ejaculation for at least 48 hours. This will help obtain a more accurate measurement of the PSA level.
Consider Other Factors:

Ensure the patient is also aware of other factors that can affect PSA levels, such as:
Recent prostate examination (e.g., digital rectal exam)
Urinary tract infection or prostatitis
Certain medications or supplements
Interpret PSA Levels in Context:

Once the PSA test is rescheduled and completed under optimal conditions, interpret the results in the context of the patient’s family history, age, and other risk factors. Elevated PSA levels may warrant further investigation, such as repeat testing, imaging, or referral to a urologist for consideration of a prostate biopsy.
Follow-Up:
Monitor PSA Levels: Depending on the initial PSA result, regular monitoring may be recommended to track any changes over time.
Risk-Based Screening: Consider a more personalized screening approach based on the patient’s family history and risk factors, potentially involving genetic counseling or more frequent PSA testing.

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