STEP 2: Presentation, initial investigations and referral

Signs and symptoms for investigation

Most patients who present with prostate cancer are asymptomatic.

Some patients present with locally advanced disease and may have the following symptoms:

  • obstructive or irritative urinary symptoms
  • blood in the urine or semen.

A small percentage of patients present with metastatic disease and may have the following symptoms:

  • back and bone pain
  • leg swelling
  • weight loss
  • fatigue
  • neurological symptoms including weak or numb legs or feet.

Initial investigations

  • PSA level
  • Measurement of the free-to-total PSA ratio
  • Midstream urine test (to check for prostatitis)

The significance of rising PSA (free-to-total PSA ratio), even within the age-adjusted normal range, should be recognised, as well as a PSA that is at the high end of the normal range in younger men.

Referral options

At the referral stage, the patient’s GP or other referring doctor should advise the patient about their options for referral, waiting periods, expertise, if there are likely to be out-of-pocket costs and the range of services available. This will enable patients to make an informed choice of specialist and health service.


The GP’s responsibilities include:

  • explaining to the patient and/or carer who they are being referred to and why
  • supporting the patient and/or carer while waiting for specialist appointments
  • informing the patient and/or carer that they can contact Cancer Council on 13 11 20.



The GP should have results and review the patient:

  • within 4 weeks for symptomatic patients and those with an abnormal digital rectal examination (DRE) or a PSA ≥ 10 ng/mL
  • within 12 weeks for asymptomatic patients (PSA < 10 ng/mL).

Urgent referral to a specialist is recommended for:

  • symptomatic patients (including psychological distress)
  • patients with radiological evidence of locally advanced or metastatic disease
  • PSA > 50 ng/mL.

Asymptomatic patients should be seen by a specialist within 4 weeks of a persistently abnormal result being identified or a single PSA reading ≥ 10 ng/mL.