Prostate cancer

Scottish referral guidelines for suspected cancer
Centre for Sustainable Delivery

Urgent suspicion of cancer (USC) referral

Refer a person with any of the following to the Urology Service as a USC:

  • Raised PSA in the following age categories: 
    • under 70: ≥3 ng/ml
    • 70-79: ≥5 ng/ml
    • 80 and above: ≥20 ng/ml - see good practice
  • A DRE suspicious of prostate cancer (hard and/or irregular) – request an urgent PSA test in parallel to a referral.

Do not refer as a USC if the PSA is raised in men with symptoms or signs of a Urinary Tract Infection (UTI), or who have been treated for a UTI. Instead, repeat the PSA after 6 weeks of completing treatment for the UTI. If the PSA is still raised (see above thresholds) refer as USC.

A UTI does not need to be excluded prior to referral if there are no clinical features of infection.

A repeat PSA test may be carried out by secondary care to allow triage but is not needed for referral from primary care if there is not a confirmed or suspected UTI.

 

Assessment for suspected prostate cancers

Early prostate cancer is often asymptomatic. Prostate cancer can present with lower urinary tract symptoms. Symptoms suggestive of advanced or metastatic prostate cancer include back pain, bone pain, fatigue, or weight loss (see Malignant Spinal Cord Compression (MSCC)).

For men aged 50 years and over, or aged 45 years and over with one or more risk factor(s)*, a Prostate Specific Antigen (PSA) test and a Digital Rectal Examination (DRE) should be considered if there are any of the following symptoms:

  • Lower urinary tract symptoms (urgency, hesitancy, frequency, nocturia, retention)
  • Unexplained visible haematuria
  • Haematospermia
  • Erectile dysfunction

*Risk factors: a first degree relative (brother or father) who has or had prostate cancer, are black or mixed black ethnicity or carry a BRCA gene variant

Do not perform a PSA test until at least six weeks after treatment for men with symptoms or signs of a Urinary Tract Infection (UTI), or who have been prescribed antibiotics for a confirmed or suspected UTI.

In men aged 80 years or over, prostate cancer is commonly found but may not be clinically significant. It is recommended that PSA testing should be reserved for men aged 80 years or over in the following scenarios:

  • Clinical features suggestive of metastatic prostate cancer (e.g. new significant bone pain, unexplained weight loss or unexplained anaemia)
  • The man wants a PSA test after shared decision-making. The potential benefits of diagnosing and treating prostate cancer are greater in those with a good functional status (Performance Status e.g. ECOG/WHO performance status and Clinical Frailty Scale) and a longer life expectancy (10 plus years).

Good practice points

There is no agreed screening programme for prostate cancer in the United Kingdom. There is an informed choice programme called the Prostate Cancer Risk Management Programme (PCRMP). This supports clinicians to give balanced information to men without symptoms of prostate disease who ask about a PSA test. The PCRMP was updated in December 2024 to clarify that PSA testing for asymptomatic men is not exclusively available to those aged 50 and over. The documents contain reference to NICE NG12. This is not relevant for NHS Scotland and instead the Scottish Referral Guidelines for Suspected Cancer should be followed for the referral of suspected prostate cancer.

If a PSA is performed in this context the following apply:

  • PSA thresholds described in the ‘Urgent Suspicion of Cancer Referral’ section above should be used to guide referral
  • If the PSA is below these thresholds, the test should not be repeated within a 12-month period, if the person remains asymptomatic

Men between the ages of 80 and 85 who have a high PSA ≥10, but <20, can be referred as urgent for further assessment, if they are fit and do not have multiple co-morbidities, in line with the principles of Realistic Medicine.

Urinary catheterisation or other invasive procedures such as prostate biopsy raise PSA, with 5- alpha reductase inhibitors such as finasteride potentially reducing PSA.

The following people have a prostate gland:

  • Men
  • Transgender women
  • Non-binary people with male as their biological sex
  • Some intersex people

If the prostate is felt to be abnormal (hard and/or irregular) on DRE, a PSA test should be requested. The result of the PSA test is used to support triage in secondary care. The PSA result should not alter the category of referral to secondary care - an abnormal DRE in the presence of a normal PSA should still be referred as a USC.

The prostate is not removed as part of genital reconstructive surgery. Transgender women and non-binary people whose biological sex is male can get prostate cancer. Taking feminising hormones, testosterone blockers or having the testicles removed reduces the risk of prostate cancer by lowering testosterone levels.

Lower urinary tract symptoms in Transgender women or non-binary people whose biological sex is male, especially if aged 50 years or over, should be assessed carefully and the possibility of prostate cancer considered. If vagino/vulvoplasty has been carried out the prostate can be examined via the anterior wall of the vagina.

 

Background

This is the most common cancer among men in Scotland, accounting for around 4,700 diagnoses each year1. Risk factors include:

  • Father or brother with prostate cancer
  • Black or mixed black ethnicity (the lifetime risk of prostate cancer in black men is double that of white men)78
  • Carrying a BRCA gene variant