What Happens After an Elevated PSA Test: The Experience of 13,591 Veterans

BackgroundThe occurrence and timing of prostate biopsy following an elevated prostate-specific antigen (PSA) test varied considerably in randomized screening trials.ObjectiveExamine practice patterns in routine clinical care in response to an elevated PSA test (≥4 ng/μl) and determine whether time to biopsy was associated with cancer stage at diagnosis.DesignRetrospective cohort study.ParticipantsAll veterans (n = 13,591) in the Pacific Northwest VA Network with a PSA ≥4 ng/μl between 1998 and 2006 and no previous elevated PSA tests or prostate biopsy.Main MeasuresWe assessed follow-up care including additional PSA testing, urology consults, and biopsies. We compared stage at diagnosis for men who were biopsied within 24 months vs. those men biopsied and diagnosed >24 months after the elevated PSA test.Key ResultsTwo-thirds of patients received follow-up evaluation within 24 months of the elevated PSA test: 32.8% of men underwent a biopsy, 15.5% attended a urology visit but were not biopsied, and 18.8% had a subsequent normal PSA test. Younger age, higher PSA levels, more prior PSA tests, no co-payment requirements, existing urologic conditions, low body mass index, and low comorbidity scores were associated with more complete follow-up. Among men who underwent radical prostatectomy, a delayed diagnosis was not significantly associated with having a pathologically advanced-stage cancer (T3/T4), although we found an increased likelihood of presenting with stage T2C relative to stage T2A or T2B cancer.ConclusionsFollow-up after an elevated PSA test is highly variable with more than a third of men receiving care that could be considered incomplete. A delayed diagnosis was not associated with poorer prognosis.