title: What happens after an elevated PSA test: the experience of 13,591 veterans.
abstract: BACKGROUND
  The occurrence and timing of prostate biopsy following an elevated prostate-specific antigen (PSA) test varied considerably in randomized screening trials.
  
  
  OBJECTIVE
  Examine practice patterns in routine clinical care in response to an elevated PSA test (≥4 ng/μl) and determine whether time to biopsy was associated with cancer stage at diagnosis.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  All veterans (n=13,591) in the Pacific Northwest VA Network with a PSA ≥4 ng/μl between 1998 and 2006 and no previous elevated PSA tests or prostate biopsy.
  
  
  METHODS
  We assessed follow-up care including additional PSA testing, urology consults, and biopsies. We compared stage at diagnosis for men who were biopsied within 24 months vs. those men biopsied and diagnosed>24 months after the elevated PSA test.
  
  
  RESULTS
  Two-thirds of patients received follow-up evaluation within 24 months of the elevated PSA test: 32.8% of men underwent a biopsy, 15.5% attended a urology visit but were not biopsied, and 18.8% had a subsequent normal PSA test. Younger age, higher PSA levels, more prior PSA tests, no co-payment requirements, existing urologic conditions, low body mass index, and low comorbidity scores were associated with more complete follow-up. Among men who underwent radical prostatectomy, a delayed diagnosis was not significantly associated with having a pathologically advanced-stage cancer (T3/T4), although we found an increased likelihood of presenting with stage T2C relative to stage T2A or T2B cancer.
  
  
  CONCLUSIONS
  Follow-up after an elevated PSA test is highly variable with more than a third of men receiving care that could be considered incomplete. A delayed diagnosis was not associated with poorer prognosis.
authors.affiliation: VA Health Services Research & Development Service, Department of Veterans Affairs Medical Center, Seattle, WA 98101, USA. Steven.Zeliadt@va.gov
authors.forename: Steven B
authors.initials: SB
authors.lastname: Zeliadt
authors.forename: Richard M
authors.initials: RM
authors.lastname: Hoffman
authors.forename: Ruth
authors.initials: R
authors.lastname: Etzioni
authors.forename: Van Anh T
authors.initials: VA
authors.lastname: Ginger
authors.forename: Daniel W
authors.initials: DW
authors.lastname: Lin
mesh_terms: D000368:Aged; D001706:Biopsy; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011467:Prostate / Q000473:pathology; D017430:Prostate-Specific Antigen / Q000032:analysis*; D011471:Prostatic Neoplasms / Q000175:diagnosis* / Q000473:pathology / Q000601:surgery; D044469:Racial Groups; D012424:Rural Population; D014481:United States; D014493:United States Department of Veterans Affairs; D014505:Urban Population; D014728:Veterans / Q000706:statistics & numerical data*
chemical_list: D017430:Prostate-Specific Antigen