As a general practitioner, checking results is part of my daily routine. For me, I have an extra level of caution when I see Prostate Specific Antigen (PSA) results, for the very reason described in a recent HDC case that eventually hit the media in which the PSA test was in normal range as described in the laboratory report.
This was a case in which the PSA levels were in the laboratory normal range and hence were filed and no further action taken. However the patient, Mr A, had had a prostatectomy for prostate cancer and the operating urologist request he be referred should his PSA become detectable again.
Following the initial advice from the urologist, a recall had been set up for six-monthly PSA tests. Over the next three years, five tests were done with detectable but a low-level PSA reading and hence were filed as “okay”. The patient was informed his tests were normal.
He then presented being unwell with a PSA of 5.7, and had developed what was in fact pancreatic cancer and also probable metastatic prostate cancer based on the scans performed. These cancers would most likely have been picked up earlier had the rising PSA been addressed appropriately.
The HDC found that several opportunities were missed. It had a long list of recommendations including a new ‘inbox’ process for results, a patient portal for sharing results, and a double recall system for post prostatectomy results.
Some tests are normal when they are normal, but some are contextual which require correlation with the patient and their particular circumstances. The PSA is one such test and therefore requires extra levels of vigilance and discipline in terms of managing this result when it arrives in the result inbox.
I do several things with my practice management system such as coding the diagnosis and commenting on any unusual requirements, for example “refer for any detectable PSA” , or “refer if PSA velocity is a certain level as recommended by the urologist”. Attaching the diagnosis to the result is another way of cross-checking, as well as it is very easy to click on the graph to track historical PSA readings.
In your routine checking of results, if the PSA does not give you cause to pause, I encourage you to change your thinking and always check what context this particular PSA level was requested. Was it part of health screening, or was it for any contextual reasons provided by advice from you urology colleagues? This case is also a timely reminder not to focus attention only on the RED abnormal results in your lab inbox.
Dr Andrew Dunn
General Practitioner