Doctor Fails to Order Additional Testing After Elevated PSA Level is Detected

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.

Question(s) For Expert Witness

1. What are the guidelines for screening when the PSA is steadily increasing?

Expert Witness Response E-014220

This is a case of delayed diagnosis of prostate cancer. The delay led to progression to metastatic disease at the time of diagnosis. The delay is often a result of errors in prostate cancer/PSA screening-detection. The basic standard of care at this time consisted of the use of PSA, DRE and/or TRUS. In addition, the use of adjunctive measures were applied to improve both sensitivity and specificity of our basic screening measures, esp. PSA. This included variant PSA measures such as PSA kinetics (PSA velocity, PSA doubling time), % free PSA, PSA density (#PSA value/volume(size) of prostate gm/cc), and biomarkers (ex urine PCA-3 test). This case is an example of failing to adhere to the proper standards for PSA/Prostate ca screening. The provider in this case failed to appreciate clinically significant PSA elevation and PSA kinetics (specifically PSA velocity) and perform a proper DRE. If physician adhered to accepted standards this would have led to further evaluation which includes biopsy and ultimately diagnosis (at earlier stage).