December 30, 2022
My PSA is Elevated, Now What?
As I have written about extensively, a man's prostate-specific antigen blood test result could be elevated for several reasons. Though we urologists always want to get to the bottom of an elevated PSA result, even if it is high, that doesn't automatically point to cancer. But once that elevated result is revealed, the next question on the minds of many men is – now what?
First, and depending on age, many men present to their doctor’s office with history of multiple PSA tests. While a single PSA data point in time may not be very informative, a data set of multiple PSAs can be very telling. Generally, we become concerned about prostate cancer if the PSA is rising faster than 0.7 ng/ml per year. Also of concern, is a PSA that has been stable over a period of time, and then experiences a significant rise. Conversely, in those patients who have a history of PSA fluctuation, we may be less concerned about cancer. Furthermore, if the PSA has been stable but suddenly becomes much higher than before, as in 3X higher, then our concern for infection may be higher than it is for the presence of prostate cancer.
It bears repeating that an elevated PSA test result can have a variety of potential causes that warrant further investigation, including, but not limited to prostate cancer, such as:
other types of infection in the body, like gastroenteritis, flu, or cold
naturally higher levels in some individuals.
It's essential to assess each of the above factors independently. Suppose the patient has recently recovered from the flu, COVID, a cold, or gastroenteritis. In that case, we may recommend waiting to perform additional testing until the illness resolves and then repeating the PSA in a few weeks. What should we do when the patient's elevated PSA levels are accompanied by symptoms of prostatitis or another urologic condition - such as burning with urination, perineal pain, urinary urgency, or suprapubic pain? In those cases, treating the symptoms with antibiotics may be best, and then repeating the PSA exam once the probable infection has cleared up.
Having ruled out the above scenarios, a urologist's next course of action typically depends on the level of suspicion they have for the presence of prostate cancer versus some of the other elevated PSA possibilities. For example, men with elevated PSAs who have a first degree relative with prostate or breast cancer are at a higher risk for the development of prostate cancer. As a result, we may be more inclined to further test these men, even if the PSA shows only a slight elevation.
Bottom line, there is no one size fits all strategy for solving why a man's PSA is elevated. Skill, experience, training, and the health of the patient-physician relationship all contribute to urologists' approach to solving the mystery of an elevated PSA.
Generally, after watchful waiting, treatment of a possible infection, and repeated PSA examination in both scenarios, the remaining options for getting to the bottom of a high PSA include further testing or the performance of a prostate biopsy. Urologists typically explore these main options for further testing an elevated PSA:
Digital Rectal Exam (DRE): This test involves the physician placing a finger ("digit") into the patient's rectum and feeling the prostate under their finger. If a hard nodule is felt on the prostate, the patient may require further testing, including a prostate biopsy.
Total and Free PSA Ratio: This blood test compares the amount of free PSA to the total PSA in the blood. If this ratio is less than 25%, the risk of prostate cancer is higher and may point to the need for additional testing or the performance of a prostate biopsy.
"Liquid Biopsy" Test: This is a urine test that looks for traceable amounts of prostate cancer DNA/RNA in a sample of the patient's urine. If the test is positive, a prostate biopsy or MRI may need to be performed.
Transrectal Prostate Ultrasound: This test examines the prostate using ultrasonography via a wand introduced into the rectum. Ultrasound of the prostate scans the prostate's shape, configuration, size, and volume. If there are irregular hypoechoic (dark) areas, especially around the peripheral edges of the prostate, then the level of suspicion increases for the presence of prostate cancer. In this case, a prostate biopsy may be warranted.
Prostate MRI: This test can evaluate the presence of prostate cancer by identifying suspicious areas in the prostate. The urologist can then use the MRI images captured from this examination with the transrectal ultrasound images to target the abnormal lesions and obtain a more accurate prostate gland biopsy.
While an elevated PSA should not necessarily ring a man's prostate cancer "alarm bells," it is an important test that can help alert him and his medical team to the need for further investigation. Thankfully, and as described above, urologists can perform various tests to help get to the bottom of why a man is experiencing a high PSA. Armed with this additional information, men, their loved ones, and their medical care teams can make the best next-step decisions for their continued health and well-being.
Sources: Email answers provided on 12/12.