Table 1

Recommendations for referral of patients with suspected prostate cancer by FPs and other PCPs

PATIENT GROUP	RECOMMENDATION	GUIDANCE FOR REFERRAL
Recommendation 1: actions for patients with unexplained symptoms of metastatic prostate cancer	A man ≥ 40 y should have a DRE and a PSA test if he has any unexplained symptoms suggestive of metastatic prostate cancer: Suspicious low back pain such as that associated with reproducible percussion tenderness Severe bone pain Weight loss, especially in the elderly	If the prostate is hard or irregular on DRE or the PSA level is ≥ 20 µg/L, the patient should receive an urgent referral, which might include additional communication (eg, telephone call, fax), and expect a consultation with a urologist or a prostate cancer DAP within 1 wk If the PSA level is between 10 and 20 µg/L, the patient should receive a semiurgent referral and expect a consultation with a urologist or a prostate cancer DAP within 2 wk c. If the PSA is < 10 µg/L, consider other metastatic cancers. If there is still a suspicion of prostate cancer, the patient should receive a nonurgent referral and expect a consultation with a urologist or a prostate cancer DAP within 4 wk
Recommendation 2: actions for patients with LUTS	For a man presenting with LUTS (irritative and obstructive voiding symptoms), a DRE should be performed and a discussion about the benefits and risks of PSA testing should occur with the patient.^* Lower urinary tract infection should be excluded before PSA testing, especially in men presenting with LUTS. The PSA test should be postponed for at least 1 mo after treatment of a proven urinary tract infection	If the prostate is hard or irregular on DRE, a PSA test should be ordered and the patient should receive a nonurgent referral and expect a consultation with a urologist or a prostate cancer DAP within 4 wk If the prostate is hard or irregular on DRE and the age-based PSA level^† is elevated but < 10 µg/L, the patient should receive a nonurgent referral and expect a consultation with a urologist or a prostate cancer DAP within 4 wk If the prostate is hard or irregular on DRE and the PSA level is between 10 and 20 µg/L, the patient should receive an urgent referral, which might include additional communication (eg, telephone call, fax), and expect a consultation with a urologist or a prostate cancer DAP within 1 wk If the PSA level is ≥ 20 µg/L, the patient should receive an urgent referral, which might include additional communication (eg, telephone call, fax), and expect a consultation with a urologist or a prostate cancer DAP within 1 wk If the DRE findings are normal and the PSA level is between 10 and 20 µg/L, the patient should receive a semiurgent referral and expect a consultation with a urologist or a prostate cancer DAP within 2 wk If the DRE findings are normal and the age-based PSA level^† is elevated but < 10 µg/L, then appropriate nomograms^‡ should be used to determine the risk of high-grade prostate cancer If the risk of high-grade prostate cancer is < 5%, annual monitoring of PSA level and DRE is recommended, assuming that repeated PSA testing is supported by the patient and FP or other PCP If the risk of high-grade prostate cancer is between 5% and 20%, discussion about other management options should occur with the patient. Based on patient preference, this could include referral to a urologist or a prostate DAP or annual or more frequent follow-up of PSA testing and DRE, assuming that repeated PSA testing is supported by the patient and FP or other PCP If the risk of high-grade prostate cancer is > 20%, the patient should receive a nonurgent referral and expect a consultation with a urologist or a prostate cancer DAP within 4 wk
Recommendation 3: actions for patients with incidental elevated PSA results	For incidental elevated age-based PSA findings, DRE should be performed for all patients. Rule out other reasons for elevated PSA values (age-related hypertrophy [BPH], infection, inflammation, prostatitis, recent sexual activity, etc). Repeat PSA testing if unsure	Guidance for referral b through f of recommendation 2 should be followed

BPH—benign prostatic hypertrophy, DAP—diagnostic assessment program, DRE—digital rectal examination, LUTS-lower urinary tract symptoms, NZGG—New Zealand Guidelines Group, PCP—primary care provider, PSA—prostate-specific antigen.
↵* For information of discussing the benefits and risks of PSA testing with patients, refer to the individual risk assessment from the Canadian Partnership Against Cancer PSA Toolkit.²
↵† An example of age-based PSA values (upper limit of normal) from the NZGG is as follows: 40–50 y, 2.5 µg/L; 50–60 y, 3.5 µg/L; 60–70 y, 4.5 µg/L; ≥ 70 y, 6.5 µg/L.⁵ Differences in PSA assay can lead to differences in age-based ranges reported by laboratories.
↵‡ Nomograms are available from http://sunnybrook.ca/content/?page=OCC_prostateCalc (includes the ratio of free PSA, unbound to serum proteins, to total PSA because this ratio is decreased in men with prostate cancer; in some cases patients might be charged a laboratory fee for this value; if this ratio is not determined, then a value of 0.1 can be entered into the risk calculator)¹¹; http://deb.uthscsa.edu/URORiskCalc/Pages/uroriskcalc.jsp¹²; or www.prostatecancer-riskcalculator.com/assess-your-risk-of-prostate-cancer.¹³ If a nomogram is not used, then the patient should receive a nonurgent referral and expect a consultation with a urologist or a prostate cancer DAP within 4 wk.