Downstream Outcomes of Elevated Prostate-Specific Antigen (PSA) Detected Through Routine Screening in Men Aged 55–70: A 10-Year Retrospective Study

Introduction Prostate-specific antigen (PSA) screening remains a contentious issue due to its high sensitivity but low specificity. While elevated PSA can indicate prostate cancer, it may also result from benign conditions such as benign prostatic hyperplasia (BPH), prostatitis, or infection. The variability in downstream management following elevated PSA in nonspecialist outpatient settings is not well-characterized. Downstream management refers to clinical follow-up measures after elevated PSA results, including referral, biopsy, repeat testing, benign diagnoses, refusal, or no further evaluation. Objective This study aimed to assess the clinical outcomes following elevated PSA levels (≥4 ng/mL) identified through routine screening in men aged 55-70 years in a primary care clinic over a 10-year period. Methods We conducted a retrospective observational study at an independent outpatient clinic in Michigan, analyzing electronic health records (EHRs) from 2015 to 2024. A total of 1,258 men aged 55-70 who underwent routine PSA testing were included. Patients with known urologic conditions or prostate cancer were excluded. Among those with elevated PSA levels, downstream outcomes such as urology referrals, biopsy status, cancer detection, benign diagnoses, repeat testing, and loss to follow-up were evaluated using descriptive statistics. Results Of 1,258 screened patients, 127 (10.1%) had PSA levels ≥4 ng/mL. Among them, 44 (34.6%) underwent biopsy, with prostate cancer confirmed in 18 patients (40.9% of biopsied; 1.4% of total screened). The remaining 83 patients (65.4%) did not undergo biopsy: 13 normalized their PSA on repeat testing, 37 were diagnosed clinically with BPH, eight had other benign causes (e.g., urinary tract infection (UTI), prostatitis), 12 declined biopsy, and 13 were lost to follow-up. These findings reveal considerable heterogeneity in follow-up care and clinical decision-making. Conclusion In this real-world primary care setting, most men with elevated PSA were managed noninvasively, with a substantial proportion avoiding biopsy. Despite this, the cancer detection rate among biopsied individuals was significant. These results underscore the need for standardized follow-up protocols and decision-support frameworks to guide post-PSA screening management in outpatient environments.