Why this matters in South Africa

Prostate cancer was the leading histologically diagnosed cancer in South African men in 2024: 10,769 observed cases, 25.18% of male cancers, and a cumulative risk to age 74 of approximately 1 in 17. In the 2024 KwaZulu-Natal population-based registry it was also the most common male cancer.^1,2

Black South African men are more likely to present with higher-grade or more advanced disease, while public-sector access to MRI, biopsy and specialist care remains uneven.³ Primary care therefore has two linked tasks: offer screening to the right asymptomatic men, and recognise symptomatic or advanced disease early without delaying referral.

Who should be offered PSA testing?

Screening means PSA testing in an asymptomatic man. Diagnostic testing is different: a symptomatic patient or a man with an abnormal examination requires clinical investigation regardless of the screening schedule. The 2024 South African Prostate Cancer Screening Guidelines support shared decision-making in asymptomatic men with a life expectancy greater than 10 years; the 2026 EAU Prostate Cancer Guideline uses a more conservative threshold of at least 15 years.^3,4

Screening intervals should be individualised according to baseline PSA, ancestry, family history, age, health status and patient preference. Do not automatically repeat PSA annually in every man with a low baseline value.

Assessment

History

• Clarify whether the patient is asymptomatic, has lower urinary tract symptoms, or has possible advanced-disease symptoms.
• Record previous PSA values and dates; avoid interpreting “velocity” from short-interval fluctuation alone.
• Ask about first-degree prostate cancer and breast, ovarian or pancreatic cancer on both sides of the family, particularly young diagnoses or multiple affected relatives.
• Record black African ancestry, known germline variants, comorbidity, functional status and realistic life expectancy.
• Identify transient PSA confounders: bacterial prostatitis, acute urinary retention, recent urethral instrumentation or TURP, ejaculation and vigorous cycling.
• Check finasteride or dutasteride use and duration; after 6–12 months these drugs commonly lower PSA by about 50%.
• Ask about haematuria, weight loss, progressive bone pain, lower-limb weakness or sensory change, and new bladder or bowel dysfunction.

Examination

Assess general condition, performance status, lymphadenopathy, pallor, spinal tenderness and neurological findings when advanced disease is possible. Examine the abdomen for a palpable bladder or renal obstruction. DRE remains useful in symptomatic men and when cancer is suspected: document size, asymmetry, nodularity, induration, fixation and tenderness.

Routine DRE adds little to PSA alone as a screening test in an asymptomatic primary-care population; however, an abnormal DRE warrants referral even when PSA is not markedly raised.³

Investigations in primary care

PSA preparation: If clinically safe, repeat a modest elevation after ejaculation and vigorous cycling have been avoided for at least 48 hours. Defer PSA for 6–8 weeks after bacterial prostatitis and for about 6 weeks after acute retention, urethral instrumentation or TURP. Do not defer when advanced cancer is suspected.

For a man established on finasteride or dutasteride for 6–12 months, the measured PSA is commonly doubled as a rough correction, but the pretreatment baseline and any rise from the post-treatment nadir are important. If the trend is concerning, refer rather than relying on the correction alone.

What should primary care treat?

Primary care does not treat presumed prostate cancer. Treat concurrent conditions on their own merits—such as culture-supported bacterial UTI/prostatitis, pain, constipation or acute retention—while arranging appropriate referral. Catheterise acute retention when indicated and check renal function. Suspected metastatic spinal cord compression is an emergency: arrange immediate hospital assessment and spinal imaging according to the local pathway; do not wait for an outpatient urology appointment.

Decision tree: PSA testing and referral

1. 1Identify the pathway: asymptomatic screening candidate OR symptomatic/abnormal examination.
2. 2If screening: confirm shared decision-making, appropriate starting age and >10-year life expectancy; obtain total PSA.
3. 3If PSA is within the age-adjusted range and DRE is not indicated/normal: agree a risk-adapted follow-up interval.
4. 4If PSA is raised but <10 ng/mL, the man is asymptomatic and DRE is normal: check confounders; repeat under standardised conditions when clinically safe; consider free/total PSA.
5. 5Refer if PSA remains above the age-adjusted range, DRE is abnormal, the PSA trend is concerning, or symptoms suggest cancer.
6. 6Expedite referral for PSA ≥10 ng/mL, a clearly malignant DRE, systemic/bone symptoms, or suspected locally advanced disease.
7. 7Send urgently to hospital for neurological deficit/possible cord compression, acute kidney injury from obstruction, sepsis, or uncontrolled pain.

Referral checklist

Include with referral: current and previous PSA results with dates; DRE findings; urinary symptoms; urinalysis/culture; renal function and relevant FBC/ALP/calcium; medications (especially anticoagulants and 5-alpha-reductase inhibitors); family history; ancestry; comorbidity and performance status; and any available imaging.

Common pitfalls

• Reassuring a patient because he has no urinary symptoms.
• Calling a raised PSA “prostate cancer” before histological diagnosis.
• Using a single universal PSA cut-off without considering age, trend, drugs and clinical context.
• Repeating PSA during prostatitis, retention or soon after instrumentation.
• Using antibiotics or alpha-blockers solely to lower an asymptomatic PSA.
• Forgetting that finasteride/dutasteride suppress PSA and that a rise from nadir can be important.
• Ordering MRI as a general screening test, or allowing imaging to delay referral for obvious advanced disease.
• Assuming an abnormal DRE is irrelevant because PSA is “normal”.

What happens after referral?

The urologist reassesses the PSA context, DRE, life expectancy and patient preferences. For suspected organ-confined cancer, the EAU recommends multiparametric MRI before biopsy. MRI and clinical variables—particularly PSA density and family history—help determine whether biopsy is needed. A suspicious MRI is sampled using targeted and perilesional cores; the 2026 EAU guideline prefers the transperineal route because of lower infectious risk and better antibiotic stewardship.⁴

If cancer is confirmed, grading uses ISUP Grade Group, followed by clinical risk stratification and staging when indicated. Management may include active surveillance, radical prostatectomy, external-beam radiotherapy, brachytherapy, androgen-deprivation therapy, systemic therapy or watchful waiting. Choice depends on disease risk, stage, health status, urinary and sexual function, resources and informed patient preference. A diagnosis does not automatically mean surgery: active surveillance is standard for appropriately selected low-risk disease.

Clinical pearls

• Early prostate cancer is usually asymptomatic.
• PSA is prostate-specific, not cancer-specific.
• Screening should be informed and risk-adapted, not opportunistic testing without discussion.
• Start earlier in black African men, men with significant family history and selected germline variants.
• A modestly raised PSA often merits one properly timed repeat—not serial delay.
• DRE is most valuable in symptomatic or clinically suspicious patients.
• Do not use antibiotics to “treat the PSA” in an asymptomatic man.
• MRI refines biopsy selection; it is not a screening replacement for PSA.
• Transperineal biopsy is preferred by the EAU when feasible.
• Neurological symptoms with suspected prostate cancer are an emergency.

Key take-home messages

• Offer PSA testing from 50 years for most well-informed men likely to benefit.
• Begin from 45 years in black African men and men with a first-degree family history of prostate and/or breast cancer.
• Begin from 40 years for selected pathogenic germline variants, with genetic counselling pathways where appropriate.
• Do not screen routinely when age, comorbidity or preference makes meaningful benefit unlikely.
• Check transient PSA confounders and 5-alpha-reductase inhibitor use.
• Repeat an asymptomatic PSA below 10 ng/mL with normal DRE under standardised conditions when clinically safe.
• Refer persistent age-adjusted elevation or any suspicious DRE.
• Do not prescribe empirical antibiotics solely for an elevated PSA.
• Escalate quickly when PSA, examination or systemic features suggest advanced disease.
• Treat possible cord compression, obstructive renal failure and sepsis as emergencies.

References

1. National Cancer Registry. Summary statistics of cancer diagnosed histologically in South Africa, 2024. National Institute for Communicable Diseases; 2026. Available from: NICD 2024 pathology report.
2. KwaZulu-Natal Population-Based Cancer Registry. Annual Report 2024. National Cancer Registry/NICD; 2026. Available from: KZN Population-Based Cancer Registry report.
3. John J, Adam A, Kaestner L, Spies P, Mutambirwa S, Lazarus J. The South African Prostate Cancer Screening Guidelines. S Afr Med J. 2024;114(5):e2194. doi:10.7196/SAMJ.2024.v114i5.2194.
4. European Association of Urology. EAU Guidelines on Prostate Cancer. Arnhem: EAU Guidelines Office; 2026.
5. Matsukawa A, Yanagisawa T, Bekku K, et al. Comparing the performance of digital rectal examination and prostate-specific antigen as a screening test for prostate cancer: a systematic review and meta-analysis. Eur Urol Oncol. 2024;7(4):697–706.
6. Wei JT, Barocas D, Carlsson S, et al. Early detection of prostate cancer: AUA/SUO guideline part I: prostate cancer screening. J Urol. 2023;210(1):46–53.
7. Marima R, Mbeje M, Hull R, et al. Prostate cancer disparities and management in southern Africa: insights into practices, norms and values. Cancer Manag Res. 2022;14:3567–3579.