PSA Testing Counselling for Asymptomatic Patient: A PLAB 2 Mock

examiner mla
Jul 7
2 min read

Updated: Jul 8

Summary:

This scenario involves counselling an asymptomatic male patient requesting a PSA (Prostate Specific Antigen) test due to a friend’s recent prostate cancer diagnosis. It assesses knowledge of PSA test indications, limitations, risk communication, and empathetic counselling to support informed decision-making.

Key Points:

General Approach to PSA Counselling

PSA is produced by both normal and cancerous prostate cells.
It is neither highly specific nor highly sensitive for prostate cancer:
- Specificity: ~75% (relatively low for a diagnostic test).
- Sensitivity: Low – a normal PSA does not rule out cancer.
PSA can be elevated due to:
- Benign prostatic hyperplasia (BPH)
- Prostatitis or infections
- Recent ejaculation
- Digital rectal examination (minor rise)
- Catheterisation or manipulation of the prostate
- Rigorous exercise

Risk and Benefit Explanation

Benefits:
- May detect prostate cancer early, allowing earlier treatment options.
Drawbacks:
- False positives leading to unnecessary distress and investigations (e.g. MRI, biopsy).
- False negatives provide false reassurance.
- Prostate cancer is often indolent (slow-growing) and may not impact life expectancy, but diagnosis can burden the patient emotionally and practically.

Focused History Essentials

Reason for wanting the test (e.g. anxiety after friend’s cancer).
Knowledge about the test.
Family history of prostate cancer.
Symptoms to rule out current pathology:
- Back pain
- Weight loss
- Haematuria
- Urinary symptoms (nocturia, frequency, hesitancy)
Lifestyle factors (especially smoking – a risk factor).
Previous PSA tests and results.
Past medical history and medications.
Empathise with concerns about friend’s cancer diagnosis.

Important Considerations

PSA test is not recommended as routine screening for asymptomatic men without risk factors.
Explain why the test is not gold standard, ensuring the patient understands risks of overdiagnosis and overtreatment.
Offer written information or leaflets for further reading.
Always use ICE (Ideas, Concerns, Expectations) to understand motivations and misconceptions.

Diagnostic Approach

Assess motivation: Why is he requesting PSA?
Take focused history: Symptoms, risk factors, family history.
Discuss PSA test:
- What it tests.
- Causes of elevated PSA.
Explain sensitivity and specificity limitations.
Discuss next steps if PSA is elevated: MRI, biopsy.
Discuss management if prostate cancer is detected.
Offer prostate examination if indicated.

Management

Counselling:
- Detailed explanation of pros and cons.
- Clarify that a PSA test is a blood test measuring antigen levels.
Further Investigations (if PSA elevated):
- MRI
- Prostate biopsy
Potential treatments for prostate cancer (if detected):
- Watchful waiting
- Surgery
- Radiotherapy
- Hormonal therapy
Safety netting:
- Advise to return if symptoms like back pain, haematuria, nocturia, or weight loss develop.
Lifestyle advice:
- Avoid smoking
- Maintain healthy weight and diet

Communication Skills

Warmly introduce self and confirm full name, age, and address.
Use clear, simple language without jargon.
Avoid stock phrases or scripted empathy – show genuine concern.
Ask about the friend’s condition and express sympathy.
Allow the patient to ask questions and answer thoroughly.
Reassure while being realistic, avoiding over-promising.

Ethical Considerations

Respect patient autonomy by providing full information for an informed decision.
Handle discussions about cancer risk with sensitivity and professionalism.
Avoid unnecessary investigations that may cause harm or distress without benefit.

Additional Resources

NICE Guidelines on PSA Testing
GMC Good Medical Practice (communication and consent standards)
Prostate Cancer UK patient information leaflets