My PSA is Elevated – What are the Next Steps?
- PSA, or prostate-specific antigen, is a protein produced by cells in the prostate gland. Elevated PSA levels may indicate prostate cancer.
- The PSA test is a common blood test used for the earlier detection and diagnosis of prostate cancer. It is also used to monitor the disease after diagnosis.
- If your PSA is elevated, you will typically be referred to a urologist for further workup. Your urologist will often order additional testing if they suspect prostate cancer.
- If tests confirm the presence of prostate cancer, sometimes additional imaging is necessary to rule out the spread of disease.
- Once all the information is in, you will discuss potential treatment options with a team of healthcare professionals, including your urologist, radiation oncologist, and medical oncologist, to decide on the best plan of action.
Normal PSA levels typically range from 0 to 4 ng/mL, although this can vary slightly based on age and other health factors.
Read MoreWhat is a PSA test?
A prostate-specific antigen (PSA) test is one of the most commonly used screening tools for prostate cancer. It is also used for tracking the disease following diagnosis and during treatment. To perform the test, your doctor will take a blood sample just like any other routine blood test.The test checks for the level of PSA circulating in the blood. While the PSA protein is produced by normal prostate cells and usually present at low levels in the blood, it can also be made by cancerous prostate cells. As the cancer cells grow and become more active than normal prostate cells, they can cause PSA levels to spike. However, PSA can also be elevated for non-cancerous reasons too.
What is an abnormal PSA test?
Usually a PSA level of 4.0 ng/mL or higher is considered high and requires further workup. However, many men with a PSA above 4.0 do not have prostate cancer and some men with a PSA below 4.0 ng/mL can have prostate cancer. It’s crucial to review your test results with your care team to understand what they mean and if you need any followup.
For some men, an elevated PSA is normal. Numerous factors can cause a rise in PSA level to including:
- Increasing age
- Enlarged prostate
- Benign prostatic hypertrophy (BPH)
- Infection of the prostate
- Recent biopsy
- Recent ejaculation
It’s worth noting that some medications can actually lower PSA levels. These include drugs used to treat hair loss or urinary problems, such as finasteride and dutasteride.
Who should undergo prostate cancer screening with PSA?
For men 55 to 69 years, the decision to be screened for prostate cancer is an individual one, according to The United States Preventive Services Task Force. Men 70 years and older should not be screened for prostate cancer.
Other organizations, including the American Cancer Society, recommend the following prostate cancer screening schedule:
- Age 50 for men with average risk of prostate cancer
- Age 45 for high-risk men, including African American men and men with a father or brother diagnosed with prostate cancer at a young age (younger than 65 years old)
- Age 40 for very high-risk men with a father or brother who died from prostate cancer at an early age
Have a discussion with your doctor to decide the right screening schedule for you. Consider getting screened earlier if you have risk factors such as family history, race, or genetic factors such as BRCA2, a gene associated with a higher risk of prostate cancer.
How is the PSA test done?
A PSA test is a routine blood test typically ordered by your primary care physician who may also perform a digital rectal exam to check your prostate health.
If the PSA test comes back normal and you do not have any concerning symptoms such as urinary retention, painful urination, or blood in the urine you will likely continue to have regular checkups and screening to keep an eye on things.
My PSA result is elevated. What’s next?
“So for a patient that’s found to have an elevated PSA, oftentimes it’s the urologist that meets that patient first, typically referred from a primary care physician,” Dr. Jonathan Lischalk, radiation oncologist at Perlmutter Cancer Center, explains.
The urologist will perform a detailed history and physical examination (including a digital rectal exam) and consider this information in combination with your current and previous PSA tests results to make decisions about further testing.
Your care team may recommend repeat PSA testing to help rule out any benign (non-cancerous) diseases such as infection or inflammation of the prostate. They may also recommend additional imaging scans such as an MRI.
What to expect from a biopsy
Since an elevated PSA does not guarantee you have prostate cancer, doctors will usually perform a biopsy to make an official diagnosis. If your doctor suspects prostate cancer you will likely undergo a biopsy. This is a procedure that involves removing a small bit of tissue to test for the presence of disease.
If the biopsy is negative (there is no cancer detected) next steps can include:
- Repeating the PSA and digital rectal exam every year or two
- Ordering another biopsy
- Obtaining an MRI if you did not have one already
If the biopsy comes back positive for cancer, take a deep breath.
A diagnosis of prostate cancer is not always an emergency. You usually have time to decide on next steps. This will likely include further discussion with your urologist and referral to radiation oncologists and medical oncologists.
“I think one really important aspect to prostate cancer care is that there’s a lot of different options and oftentimes those options can be really challenging and maybe even the most challenging decision that a patient makes,” Dr. Lischalk notes.
Depending on what the biopsy shows, you might need additional imaging with MRI or CT (if not already done), bone scan, or a PET scan.
“We have a lot of more advanced ways to review the biopsy as well, including kind of a genomic analysis, which really digs into the DNA and the genetics of the cancer cell, which has changed the way that we approach a lot of cases,” Dr. Lischalk says.
Once your care team reviews all of the information, your prostate cancer will be grouped into localized disease, regional disease (involving a lymph node), or metastatic disease, which means it has spread to distant sites in the body. Localized disease that is only in the prostate will be assigned a risk group ranging from very low risk to very high risk.
Based on your prostate cancer category, overall health, and treatment goals, your care team will discuss the available treatment options and what is right for you.
“It’s a very complex process that involves a lot of coordination with the different specialties,” Dr. Lischalk says. “But the goal is to provide the most personalized treatment that takes into account your specific disease and health, as well as your wants and wishes.”
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