# Suspected Prostate Cancer (Referral) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: NICE NG12 Suspected cancer: recognition and referral, recommendations 1.6.1-1.6.3 (NCBI Bookshelf NBK555330) · NICE NG12 age-specific PSA thresholds, table 1 (as reproduced in PMC9888566) - Verified date: 2026-08 ## Verified against - NICE NG12 Suspected cancer: recognition and referral, recommendations 1.6.1-1.6.3 (NCBI Bookshelf NBK555330) - Suspected Prostate Cancer (Referral) - disease-level clinical article (prostate-cancer-referral-full.txt) ## Treatment metadata - No drug therapy in primary care (Urgent Referral) ## Complete treatment card ```text SUSPECTED PROSTATE CANCER (REFERRAL) Sources: NICE NG12 Suspected cancer: recognition and referral, recommendations 1.6.1-1.6.3 (NCBI Bookshelf NBK555330) · NICE NG12 age-specific PSA thresholds, table 1 (as reproduced in PMC9888566) Review status: REVIEWED against NICE NG12 Suspected cancer: recognition and referral, recommendations 1.6.1-1.6.3 (NCBI Bookshelf NBK555330), Suspected Prostate Cancer (Referral) - disease-level clinical article (prostate-cancer-referral-full.txt) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (6) - Early disease is usually silent, but it can cause BPH-like urinary symptoms such as frequency, nocturia, a weak or hard-to-start stream, blood in the urine, or painful urination [blood in the urine · burning on passing urine · nocturia] - Sexual difficulty such as trouble achieving an erection or painful ejaculation can occur - Spinal cord compression from spread can bring tingling, leg weakness, pain, paralysis, and loss of bladder or bowel control [leg weakness · paralysis · tingling] - Bone spread often causes severe pain, most often in the spine, pelvis, hips, or ribs, with femoral spread usually hitting the upper part of the bone - A family history of the disease, African American ethnicity, and germline BRCA1/BRCA2 mutations raise the risk; a family colon-cancer history raises concern for Lynch syndrome - The late picture is fatigue from anaemia, bone pain, paralysis from spinal spread, and kidney failure once both ureters are obstructed [anaemia · bone pain · fatigue · paralysis] SIGNS - what you find (2) - A firm or hard nodule on digital rectal exam is the most common positive physical finding - Asymmetry or general firmness may also be found, and a rock-hard gland strongly suggests at least locally advanced disease TESTS (12) - An elevated PSA, typically above about 4 ng/mL, is how most prostate cancers first come to light, though it correctly flags cancer only about a quarter to a third of the time - At least two abnormal PSA readings or a palpable nodule on exam are needed before pursuing a biopsy - Guidance now favors PSA screening for men 45 to 75 after a shared discussion of pros and cons rather than blanket testing - A free-PSA fraction above 25% suggests under 10% cancer risk, while under 10% free PSA implies roughly a 50% risk, when total PSA sits between 4 and 10 - A PSA density above 0.15, calculated from total PSA divided by prostate volume, suggests malignancy - A rising PSA of more than 0.75 ng/mL or over 25% a year is suspicious when total PSA is 4-10; a 0.35 ng/mL yearly rise is suspicious when total PSA is 2.6-4 - On MRI, a PI-RADS score of 1-2 makes cancer unlikely and 4-5 is highly suspicious for significant disease; biopsy is advised for any score of 3 or above - Roughly one in five biopsied PI-RADS 3 lesions turns out to be intermediate- or high-grade cancer - A TRUS-guided needle biopsy showing cancer on histology is still the only test that can conclusively confirm the diagnosis - PSMA PET/CT is becoming the preferred scan for staging intermediate or advanced disease and for catching early recurrence - PSMA PET recurrence-detection rates climb sharply with PSA level, from 45% under 0.5 ng/mL up to 94% at 2 ng/mL or above - Genomic tests run on a biopsy specimen can estimate prognosis and aggressiveness, chiefly to help choose surveillance versus treatment in low- and intermediate-risk disease IF NOT THIS - what else fits (1) - Acute and chronic bacterial prostatitis, a prostatic abscess, nonbacterial prostatitis, benign prostatic enlargement, and genitourinary tuberculosis are on the differential Source StatPearls "Prostate Cancer" - disease-level clinical article Status traced to the source above 1. NO DRUG THERAPY IN PRIMARY CARE (URGENT REFERRAL) [1st line] Adult Refer urgently if the prostate feels malignant on digital rectal examination - whatever the PSA. Otherwise consider PSA and DRE in anyone with lower urinary tract symptoms (nocturia, frequency, hesitancy, urgency, retention), erectile dysfunction, or visible haematuria, and refer if the PSA is above the threshold for age: 40-49 above 2.5, 50-59 above 3.5, 60-69 above 4.5, 70-79 above 6.5 micrograms/L. Under 40 and over 79, use clinical judgement - Person to receive a diagnosis or ruling out of cancer within 28 days of being referred urgently by their GP for suspected cancer. Peds Adult-only condition - paediatric section not applicable Source NICE NG12 Suspected cancer: recognition and referral, recommendations 1.6.1-1.6.3 (NCBI Bookshelf NBK555330) Why A hard, irregular prostate goes on the urgent pathway on its own - a normal PSA does not undo that finding, and waiting for one is how these get missed. The age bands exist because the prostate enlarges with age and a flat cut-off sends too many seventy-year- olds and too few forty-year-olds. Caution Do not take the PSA within the specific windows that falsely raise it: an active urinary infection, in the 48 hours after ejaculation or vigorous exercise, after a digital rectal examination, or after prostate instrumentation. Finasteride and dutasteride roughly halve the PSA. In a man on either, double the reading before comparing it with the threshold. Lower urinary tract symptoms are far more often benign prostatic hyperplasia than cancer - but the symptoms do not distinguish them, which is why the examination and the PSA are the decision and not the history. Bone pain with lower urinary tract symptoms is metastatic disease until proven otherwise. Refer, do not investigate the back pain first. RED FLAG - Spinal cord compression or metastatic bone pain is a presentation demanding urgent action, not just PSA/DRE-threshold referral. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)