If Screening Test Results Arent Normal
If you are screened for prostate cancer and your initial blood PSA level is higher than normal, it doesnt always mean that you have prostate cancer. Many men with higher than normal PSA levels do not have cancer. Still, further testing will be needed to help find out what is going on. Your doctor may advise one of these options:
- Waiting a while and having a second PSA test
- Getting another type of test to get a better idea of if you might have cancer
- Getting a prostate biopsy to find out if you have cancer
Its important to discuss your options, including their possible pros and cons, with your doctor to help you choose one you are comfortable with. Factors that might affect which option is best for you include:
- Your age and overall health
- The likelihood that you have prostate cancer
- Your own comfort level with waiting or getting further tests
If your initial PSA test was ordered by your primary care provider, you may be referred to a urologist for this discussion or for further testing.
Serum Insulinlike Growth Factor
Insulinlike growth factor -1, its binding protein , and its receptor have been implicated in the development of prostate cancer. PSA cleaves IGF-1 from its binding protein, allowing this potent growth factor to act on prostate epithelial cells.
Plasma concentrations of IGF-1 have been associated with an increased risk of prostate cancer. In the Physiciansâ Health Study, 152 cases of prostate cancer were matched with 152 controls from the population of 14,916 physicians. Serum samples assayed for IGF-1 at the outset of the study found a positive association with the subsequent development of prostate cancer. Men in the highest quartile for IGF-1 had a relative risk of 2.4 as compared with men in the lowest quartile.
The predominant IGF-1 binding protein, IGFBP-3, has growth-inhibiting properties that diminish the effect of IGF-1. After correcting for IGFBP-3 levels, the risk of developing prostate cancer was 4.5 times greater for the highest quartile than for the lowest quartile.
The clinical usefulness of this assay has yet to be demonstrated, because alternative explanations for these findings may exist. Prostate size and a large overlap in actual values limit the utility of the test but do provide additional information regarding the biology of prostate cancer.
What Is A Prostate
A prostate-specific antigen test measures the level of PSA in your blood. The prostate is a small gland that is part of a man’s reproductive system. It is located below the bladder and makes a fluid that is part of semen. PSA is a substance made by the prostate. Men normally have low PSA levels in their blood. A high PSA level may be a sign of prostate cancer, the most common non-skin cancer affecting American men. But high PSA levels can also mean noncancerous prostate conditions, such as infection or benign prostatic hyperplasia, a noncancerous enlargement of the prostate.
Other names: total PSA, free PSA
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Psa Level Risk Analysis
- 15% of men with a PSA level less than 4 ng/ml go on to develop prostate cancer.
- 31% of men with PSA levels between 4 10 ng/ml have shown to develop prostate cancer.
- 50% 65% of men with psa scores over 10 ng/ml develop prostate cancer.
An important part of the your results is finding both the
1. Total amount of PSA in your blood.
2. Ratio of free vs bound PSA.
What Does A High Psa Level Mean
High PSA levels could be a sign of prostate cancer or a different condition like prostatitis or an enlarged prostate.
Other things can affect your PSA level:
- Age. Your PSA will normally go up slowly as you get older, even if you have no prostate problems.
- Medications. Some drugs may affect blood PSA levels. Tell your doctor if youâre taking dutasteride or finasteride . These drugs may falsely lower PSA levels by half of what they should be.
If your PSA level is high, your doctor may suggest that you get a prostate biopsy to test for cancer.
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How Is Bph Diagnosed
Diagnosing BPH in its earlier stages can lower the risk of developing complications. Delay can cause permanent bladder damage for which BPH treatment may be ineffective. In addition to a complete medical history and physical examination, diagnostic procedures for BPH may include the following:
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Digital rectal exam. A procedure in which the doctor inserts a gloved finger into the rectum to examine the rectum and the prostate gland for signs of cancer.
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Intravenous pyelogram. A series of X-rays of the kidney, ureters, and bladder with the injection of a contrast dye into the vein to detect tumors, abnormalities, kidney stones, or any obstructions, and to assess renal blood flow.
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Cystoscopy . An examination in which a scope–a flexible tube and viewing device–is inserted through the urethra to examine the bladder and urinary tract for structural abnormalities or obstructions, such as tumors or stones.
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Urine flow study. A test in which the patient urinates into a special device that measures how quickly the urine is flowing. A reduced flow may suggest BPH.
Pros And Cons Of The Psa Test
Pros:
- it may reassure you if the test result is normal
- it can find early signs of cancer, meaning you can get treated early
- PSA testing may reduce your risk of dying if you do have cancer
Cons:
- it can miss cancer and provide false reassurance
- it may lead to unnecessary worry and medical tests when there’s no cancer
- it cannot tell the difference between slow-growing and fast-growing cancers
- it may make you worry by finding a slow-growing cancer that may never cause any problems
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Diseases That Cause Elevated Psa Levels
1. Age-related benign prostatic hyperplasia
A significant enlargement of the prostate gland can cause your PSA level to rise. While the overall volume of the prostate tends to increase in men as they age, the increase actually develops only in the transitional zone of the prostate as an abundance of nodules form and begins to compress the peripheral zone. While men often donât notice the growth directly, it can manifest itself in a more frequent urge to urinate.
2. Age-related BPH combined with chronic inflammation
In addition to BPH, chronic inflammation of the prostate can also lead to an elevated PSA level. In such cases, the two factors can act independently of one another, with each contributing to varying degrees to an increase in your PSA level.
3. Age-related BPH combined with prostate cancer
After learning from their urologists that they have benign prostatic hyperplasia, many men assume that this must also be the reason for their elevated PSA levels. However, while the enlargement will certainly tend to increase their PSA levels, prostate cancer may also be playing a role, for instance, by causing a continuous rise in their PSA levels.
4. Age-related BPH combined with acute prostatitis
5. Age-related BPH combined with multiple different tumors
What Causes A Raised Prostate Specific Antigen Level
A raised PSA level may mean you have prostate cancer but about two out of three men with a raised PSA level will not have prostate cancer.
Other conditions may also cause a raised PSA level, including:
- Transurethral resection of the prostate operation. TURP is a prostate operation used if you have benign enlargement of the prostate.
- If you have a tube to help pass urine
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How Is Psa Testing Used In The Management Of Prostate Cancer After Treatment
A periodic PSA determination is used to detect disease recurrence after treatment. Serum PSA should decrease and remain at undetectable levels after a radical prostatectomy . An increase in the PSA over time after radical prostatectomy is suggestive of recurrent prostate cancer. Similarly, failure of the PSA to decrease to an undetectable level after radical prostatectomy may indicate residual prostate cancer. Similarly, serum PSA should fall to a low level following radiation therapy, high intensity focused ultrasound, and cryotherapy and remain at or near this level over time.
What Is Screening For Prostate Cancer
Some men get a PSA test to screen for prostate cancer. Talk to your doctor, learn what is involved, and decide if a PSA test is right for you.
Cancer screeningexternal icon means looking for cancer before it causes symptoms. The goal of screening for prostate cancer is to find cancers that may be at high risk for spreading if not treated, and to find them early before they spread.
If you are thinking about being screened, learn about the possible benefits and harms of screening, diagnosis, and treatment, and talk to your doctor about your personal risk factors.
There is no standard test to screen for prostate cancer. Two tests that are commonly used to screen for prostate cancer are described below.
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The Role Of A Psa Level As An Indicator
It is not possible to diagnose a specific prostate disease solely on the basis of a PSA test. PSA levels may increase as a result of malignant, acute or age-related changes in the prostate.
Some men may even have all three of the common diseases that affect the prostate, with each disease contributing variously to an elevated PSA level.
The PSA level may reflect all of the relevant changes in the prostate. It is regarded as conspicuous when it is elevated or when it fluctuates.
The PSA level is a good indicator and should only be regarded as an indicator. When taken alone, it offers no certainty as to any specific changes to the prostate and cannot be used as a basis for a diagnosis.
In contrast, an MRI scan of the prostate does provide a reliable basis for a diagnosis.
MRI scans generate hundreds of high-resolution, cross-sectional images of the prostate gland. These images can reveal any changes that may have occurred in the tissue. Using the latest technology and multi-parametric software, we at the ALTA Klinik can even detect very small, early-stage changes in the prostate.
Recommendations For Psa Testing
According to a 2019 position statement from the European Association of Urology, a baseline PSA test in men aged 45 years at risk of prostate cancer should be used in combination with family history, ethnicity, and other factors to establish individualized screening frequency.
The American Urological Association and the American Cancer Society offer divergent recommendations on prostate-specific antigen screening. The AUA recommends baseline PSA testing, along with digital rectal examination , at age 40 for all men with a life expectancy of 10 years or more, with subsequent testing intervals determined on the basis of the PSA level and DRE results.
The ACS does not specify an age at which to pursue screening in asymptomatic men with a life expectancy of 10 years or more rather, the ACS advises clinicians to provide men with information on the risks and benefits of screening so the patient can make an informed decision. In addition, the ACS recommends that men whose initial PSA level is below 2.5 ng/mL can be screened every 2 years, but men with higher PSA values should be tested annually.
From these findings, the investigators concluded that potentially curable prostate cancer is not compromised when measuring PSA every other year in men with PSA levels of 2 ng/mL or less, as long as the DRE findings are normal.
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What Is The 4k Biomarker
The 4kscore test measures free and total PSA, human kallikrein 2 , and intact PSA and considers age, digital rectal exam results, and prior biopsy status. The test result reports the percent likelihood of finding high-grade prostate cancer on a prostate biopsy result. This test is not approved by the FDA, rather it is regulated as a laboratory-developed test. No cutoff threshold has been established for this test. Currently, the NCCN recommendations are that this test can be considered in patients prior to biopsy and for those with a prior negative prostate biopsy who are thought to be at higher risk for a high grade prostate cancer.
How To Get Tested
Samples used for PSA testing are collected by trained health care professionals at hospitals, labs, and other medical settings. Before getting tested, its best to talk to your doctor about the risks and benefits of PSA testing. You may be able to schedule your own PSA test at a clinic or laboratory without a doctors order. However, you will need a doctor to interpret the results of your test and recommend next steps.
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What Is The Controversy Surrounding Psa Screening
In recent years, there has been some controversy surrounding the PSA test. In 2012, the U.S. Preventive Services Task Force assigned the PSA test a D rating. This meant that the USPSTF concluded the harms that resulted from PSA testing, such as unnecessary biopsies and negative treatment side effects, outweighed the benefits of finding and managing the disease early. This recommendation did not include exceptions for men at increased risk of developing the disease, such as African American men, those with a family history of the disease, and those with BRCA gene mutations. The USPSTF recommendation is important as it guides primary care physicians in preventive care and can impact insurance coverage and reimbursement for screening. Prior to its D rating, the PSA test had an I rating, meaning the USPSTF concluded there was insufficient evidence to assess the pros and cons of testing.
In May 2018, the USPSTF updated their recommendation on PSA screening. In response to new research demonstrating the benefits of PSA screening , an increase in the number of men choosing active surveillance, and advocacy efforts, the USPSTF released a draft recommendation in April 2017 that assigns the PSA test a C rating for men ages 55to 69 . This rating has now been certified official by the task force.
If I Have Elevated Psa Levels What Should I Ask My Healthcare Provider
If you have any symptoms of prostate cancer, or if it runs in your family, ask your provider:
- Should I have regular tests to check my PSA level?
- What can I do to lower my risk for prostate cancer?
- What other tests or monitoring do I need?
- What are my treatment options if I get prostate cancer?
- What other signs or symptoms should I look out for?
A note from Cleveland Clinic
An elevated PSA level can be a sign of prostate cancer, but it doesnt always mean you have cancer. Your healthcare provider will watch you and do more tests to arrive at a diagnosis. Prostate cancer is often slow-growing and may never become life-threatening. If you have symptoms of prostate problems, such as difficulty urinating, don’t hesitate to let your provider know.
Last reviewed by a Cleveland Clinic medical professional on 04/06/2021.
References
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When Should I Get A Psa Test
The guidelines below are adapted from the NCCN Clinical Practice Guidelines In Oncology for Prostate Cancer Early Detection. Please use these guidelines to have a discussion with your physician about your personal risk and make a plan for screening.
- If you are between ages 45 and 75:
- Discuss the risks and benefits of prostate cancer screening with your doctor, have a baseline PSA, and consider a baseline DRE
- If your PSA is below 1 ng/mL and your DRE is normal, repeat testing every 2-4 years
- If your PSA is between 1 and 3 ng/mL and your DRE is normal, repeat testing every 1-2 years
- If your PSA is greater than 3 ng/ML or your DRE is very suspicious, your doctor may suggest additional testing or a biopsy
What’s A Raised Psa Level
The amount of PSA in your blood is measured in nanograms of PSA per millilitre of blood .
If you’re aged 50 to 69, raised PSA is 3ng/ml or higher.
A raised PSA level in your blood may be a sign of prostate cancer, but it can also be a sign of another condition that’s not cancer, such as:
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Ratio Of Free Psa To Total Psa
The ratio of free PSA to total PSA is calculated by dividing the amount of free PSA by the amount of total PSA. If the ratio of free PSA is less than 20%, the protein concentration qualifies as elevated. Cancer cells tend to produce more protein in general and more bound PSA in particular. Prostate cancer can therefore lead to an increased PSA level.
If the ratio of free PSA is above 20%, the protein concentration does not qualify as elevated and the likelihood of cancer is regarded as low.
However, experience shows that the free-to-total PSA ratio does not provide a sufficient basis for a diagnosis. That is why we at the ALTA Klinik donât rely on free-to-total PSA ratios. Instead, we use the ratios merely as an additional indicator of the advisability of an MRI scan.
What Are The Limitations Of The Psa Test
The level of PSA is a continuous parameter the higher the value, the higher the probability of having prostate cancer. On the other hand, men may have prostate cancer despite low levels of PSA. In a U.S. prevention study, 6.6% of the men whose PSA level was less than 0.5 ng/mL had prostate cancer. Thus, although age and ethnicity-based normal reference ranges exist, they have limitations. Furthermore, PSA does not allow one to predict the likelihood of clinically significant prostate cancer being present, thus subjecting men to potentially unnecessary biopsy and treatment and the morbidity associated with these.
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