Do you use the highest or most recent PSA for risk stratification for newly diagnosed prostate cancer?

This happens on occasion and can be a dilemma. First, I would repeat the PSA and see if it is <20 or >20, and take that into account. I would also take into account the genomic score. This may help further clarify the patient's risk category. If the patient had a reason for the first elevated PSA like sex, DRE, prostatitis, that would also be useful information to consider. All of this should be discussed with the patient since oftentimes these decisions are not clear cut, and the patient's comorbidities, age, and treatment preferences (being treated as the worst-case scenario versus best-case scenario) further influence the decision.