Elevated PSA: A Guide To Men
Dr. Alex Shteynshlyuger is a fellowship-trained urologic oncologist and a robotically-trained surgeon who specializes in all aspects of care for early, advanced and metastatic prostate cancer. He practices at New York Urology Specialists. He is a member of the Society for Urologic Oncology as well as American Society for Clinical Oncology.
Elevated PSA: How High is High?
it is important to understand that PSA test when used for predicting prostate cancer risk is not a “Yes” or “No” test.
There is no specific cutoff for PSA test. Because PSA varies from man to man as a result of age, genetic profile, prostate size, and a number of other variables the values that are considered elevated are patient specific.
Typically lower values of PSA are considered to be elevated in younger men as they are expected to have much lower values than older men. So in a 45-year-old man, PSA of 3.5 would be considered elevated; while in a 75-year-old male PSA of 3.5 may not be considered elevated.
The complicating issue is what we call the PSA velocity, which is a rate of change in PSA over time. Increased PSA velocity can be associated with increased risk for prostate cancer. As a result, the same 75-year-old male with PSA of 3.5 may be considered at high risk for prostate cancer if his PSA went up from 2.5 to 3.5 over a period of 1 year.
The biggest challenge when it comes to PSA values is in the range of PSA values under 10. With PSA values in the range of 10-20, men are increasingly likely to have prostate cancer; men with PSA over 20 are at particularly high risk. Most men with PSA >20 are eventually diagnosed with prostate cancer, often aggressive.
What is PSA?
PSA stands for prostate-specific antigen. It’s a blood test. Prostate-specific antigen (PSA) is a glycoprotein enzyme produced by both prostate epithelial cells and prostate cancer cells and is the most commonly used serum marker for cancer.
Your doctor will look at your PSA results and must consider your age, your race, family history, medications that you are taking, and many other variables to decide whether your PSA is normal or abnormal.
What You Should Know About PSA
Some commonly used medications for enlarged prostate, called 5-alpha-reductase inhibitors, can cause PSA decrease by about 50%. This does not decrease the risk of prostate cancer and the number needs to be doubled in men taking these common medications: Proscar (finasteride), Avodart (dutasteride), Jalyn (dutasteride plus tamsulosin). A man taking Proscar for 6 months with a PSA of 5.6 measured after 6 months, has a corrected PSA of 10.2.
PSA levels vary with age. Commonly used normal ranges are as follows:
- Men below age 50: Normal PSA less than 2.5 ng/mL
- Men 50 – 59 years: Normal PSA level less than 3.5 ng/mL
- Men 60 – 69 years: Normal PSA level less than 4.5 ng/mL
- Men older than 70 years: Normal PSA level less than 6.5 ng/mL
These results may vary between different labs according to different measurements and samples used.
What Other Conditions Can Cause a Rise in PSA?
- BPH (benign prostatic hyperplasia)
- UTI (urinary tract infection)
- Recent prostatic intervention such as a prostate biopsy
- Recent catheterization or cystoscopy
What are the factors that raise the suspicion of prostate cancer when having an abnormal or Elevated PSA level?
- Older age
- Race (prostate cancer has a higher incidence in African-Americans)
- Presence of urinary symptoms such as hematuria (blood in urine), urinary frequency (wanting to urinate more often even if only a few drops of urine ), urgency (urgent need to urinate), a sensation of incomplete bladder emptying, split urine stream.
- If you had a PSA test in the past and a subsequent test shows a significant increase even if the value is still in the normal range.
- If your doctor finds a prostatic lump or nodule during DRE (digital rectal examination)
- Other risk factors such as a positive family history of prostate cancer or breast cancer
What are the precautions that should be taken before PSA testing:
- Be sure to tell your doctor about any drugs you are currently on. Some drugs may cause your PSA levels to be falsely low. These include finasteride (Proscar), dutasteride (Avodart), and antiandrogen drugs, such as flutamide, nilutamide, and bicalutamide (Casodex)
- Be sure to tell your doctor about any anticoagulant therapy you are currently receiving such as coumadin and aspirin
- Digital rectal examination causes a modest increase in PSA but it is not clinically important
- Prostate biopsy causes an immediate elevation in the serum PSA level which usually returns to a stable baseline level within three weeks. PSA is usually not performed within a month after a prostate biopsy.
- Recent ejaculation and sexual intercourse can lead to a mild increase in PSA which is not clinically important
What are the controversies about PSA screening?
Since the introduction of PSA screening for prostate cancer in 1997, there have been many controversies regarding elevated PSA levels. Misuse of the test for screening has created unnecessary anxiety and increased costs and has led to the significant overdiagnosis and overtreatment of men.
It is necessary only to use a single PSA determination as a baseline, and to do a biopsy for those with significant PSA changes over time, or for those with clinical manifestations mandating immediate therapy (as urinary symptoms). PSA should also be used to monitor disease progression or recurrence.
What is a prostate biopsy?
It is a minimally invasive procedure that can be done in a urologist office. In this procedure, a special biopsy needle is inserted most commonly through the rectum (TRUS) to remove small pieces of tissue from different zones of the prostate (optimally 12 pieces) and then examined under the microscope in a Pathology lab to rule out the presence of prostate cancer.
When should you undergo a prostate biopsy?
- PSA level > 4 ng/mL for men over age 60
- High PSA velocity which is a significant change in PSA level between 2 consecutive results
- Presence of prostate lump during DRE in correlation with high PSA level
- When the PSA level is higher than 50 ng/ mL, it is 98.5% accurate in predicting the presence of prostate cancer
Are there any risks associated with prostate biopsy?
Prostate biopsy is a minimally invasive procedure if done by an experienced urologist. Patients commonly experience hematuria (blood in urine), mild pelvic pain, dysuria (difficult micturition) after the biopsy is done. Infection is one of the serious side effects that can occur after prostate biopsy and it can range from mild fever to infection that requires hospitalization.
What are the other tests used in screening for prostate cancer?
Urinary prostate cancer antigen 3 (PCA3)
It is a urinary marker used in predicting the presence of prostate cancer. It offers slightly better predictive power for prostate cancer than PSA but that is not valuable in an individual patient as the benefit is small.
Prostate Health Index (PHI)
A new PSA isoform called p2PSA was recently identified. The Prostate Health Index (PHI) is a new formula that combines total PSA, free PSA, and p2PSA into a single score that can be used to aid in the diagnosis of prostate cancer. It is equal to (p2PSA/free PSA) × √PSA
PHI significantly improves the prediction of biopsy outcome (whether benign or malignant) over PSA alone. The number of unnecessary biopsies can be reduced by using PHI.
PHI was found to be more accurate than PCA3 for predicting prostate cancer in the initial biopsy and repeated biopsy.
Both Prostate Health Index (PHI) and Prostate Cancer Antigen 3 (PCA3) significantly improve prostate cancer detection at initial biopsy in a total PSA range of 2-10 ng/mL
This is a new test that was presented at the American Urological Association (AUA) 2014 Annual Scientific Meeting.
The difference between 4KScore Test and PHI test discussed earlier is that it combines 3 PSA measurements (total, free, and intact) with another new prostate-specific measurement called human kallikrein 2 (hK2) in an algorithm.
This algorithm also takes into account the patient’s age, DRE, and previous biopsy results.
The advantage of this test is that it can differentiate between pathologically insignificant and aggressive disease and thus it reduces unnecessary biopsies.
- NCCN guidelines for Prostate cancer
We see patients from all parts of New York City (Manhattan, Brooklyn, Queens, Bronx, Staten Island), Long Island, Westchester and New Jersey as well as other parts of the USA. We also see international patients from Canada, Japan, South America, Russia, Asia, Europe, Middle East, Africa, the Caribbean and other parts of the world.