STEP 2: Presentation, initial investigations and referral
This step outlines the process for the general practitioner to initiate the right investigations and refer to the appropriate specialist in a timely manner. The types of investigations the general practitioner undertakes will depend on many factors, including access to diagnostic tests, the availability of medical specialists and patient preferences.
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 (Cancer Australia 2017a).
A small percentage of patients present with metastatic disease. These patients may experience the following symptoms:
- back and bone pain
- leg swelling
- weight loss
- fatigue
- neurological symptoms including weak or numb legs or feet.
Presenting symptoms should be promptly and clinically triaged with a health professional.
General practitioner examinations and investigations should include testing PSA levels and evaluating the levels with reference to the effects of age on the normal range.
The significance of a rising PSA in a patient, even if the levels are 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. Measuring the free-to-total PSA ratio may be helpful in assessing the clinical significance of an elevated PSA. Some high-risk prostate cancers do not produce much PSA and therefore in symptomatic men a digital rectal examination (DRE) should also be conducted, even if the PSA is in the normal range.
An abnormal PSA result should be discussed with the patient face to face and information (including the significance of an abnormal result and the steps in evaluation) provided.
In asymptomatic men with an elevated PSA, total PSA as well as free-to-total ratio should be assessed one to three months after the initial abnormal test. It is recommended that, in addition, all patients should undergo a midstream urine test (to check for prostatitis).
- The general practitioner should have results and review the patient within four weeks for symptomatic patients and those with an abnormal DRE or a PSA ≥ 10 ng/mL.
- The general practitioner should have results and review the patient within 12 weeks for asymptomatic patients (PSA < 10 ng/mL).
If the cancer diagnosis is confirmed or the results are inconsistent or indeterminate, the general practitioner must refer the patient to an appropriate specialist (urologist) to make the diagnosis.
If extensive metastatic disease is suspected, then referral to a urological oncologist, urology clinic or specialist (urologist, medical oncologist or radiation oncologist) is recommended.
Patients should be enabled to make informed decisions about their choice of specialist and health service. General practitioners should make referrals in consultation with the patient after considering the clinical care needed, cost implications (see referral options and informed financial consent), waiting periods, location and facilities, including discussing the patient’s preference for health care through the public or the private system.
Referral for suspected or diagnosed prostate cancer should include the following essential information to accurately triage and categorise the level of clinical urgency:
- important psychosocial history and relevant medical history
- family history, current symptoms, medications and allergies
- results of current clinical investigations (imaging and pathology reports)
- results of all prior relevant investigations
- notification if an interpreter service is required.
Many services will reject incomplete referrals, so it is important that referrals comply with all relevant health service criteria.
If access is via online referral, a lack of a hard copy should not delay referral.
The specialist should provide timely communication to the general practitioner about the consultation and should notify the general practitioner if the patient does not attend appointments.
Aboriginal and Torres Strait Islander patients will need a culturally appropriate referral. To view the optimal care pathway for Aboriginal and Torres Strait Islander people and the corresponding quick reference guide, visit the Cancer Australia website. Download the consumer resources – Checking for cancer and Cancer from the Cancer Australia website.
Urgent referral is recommended for:
- symptomatic patients (including psychological distress)
- 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 PSA result or a single PSA reading ≥ 10 ng/mL.
The patient’s general practitioner should consider an individualised supportive care assessment where appropriate to identify the needs of an individual, their carer and family. Refer to appropriate support services as required. See validated screening tools mentioned in Principle 4 ‘Supportive care’.
A number of specific needs may arise for patients at this time:
- assistance for dealing with the emotional distress and/or anger of dealing with a potential cancer diagnosis, anxiety/depression, interpersonal problems and adjustment difficulties
- counselling for decision regret and fear of cancer recurrence
- management of physical (lower urinary tract) symptoms including difficulty starting to urinate, frequent urination (particularly at night), difficulty stopping the flow of urine and poor urine flow, incontinence and sexual dysfunction issues
- encouragement and support to increase levels of exercise (Cormie et al. 2018; Hayes et al. 2019).
For more information refer to the National Institute for Health and Care Excellence 2015 guidelines, Suspected cancer: recognition and referral.
For additional information on supportive care and needs that may arise for different population groups, see Appendices A and B, and special population groups.
The general practitioner is responsible for:
- providing patients with information that clearly describes to whom they are being referred, the reason for referral and the expected timeframes for appointments
- requesting that patients notify them if the specialist has not been in contact within the expected timeframe
- considering referral options for patients living rurally or remotely
- supporting the patient while waiting for the specialist appointment (Cancer Council nurses are available to act as a point of information and reassurance during the anxious period of awaiting further diagnostic information; patients can contact 13 11 20 nationally to speak to a cancer nurse)
- providing a mental health care plan to engage with a psychologist, especially if the patient has a history of mental health issues.
Refer to Principle 6 ‘Communication’ for communication skills training programs and resources.
