What is an Elevated PSA?
What is a PSA and why is it being checked?
PSA for a urologist stands for prostate-specific antigen. The function of PSA is to help to make your ejaculate more ‘liquidy’ when it gets into the female reproductive tract to help your sperm swim better. The reason it is checked is that it can (keyword, here) be a marker for prostate cancer. This is why during your yearly physical if you have an elevated PSA, you will be referred to a urologist for further workup.
How is my PSA checked?
This is done through a simple blood draw. Separately, your primary care physician or urologist will perform a ‘digital rectal exam’, or DRE for short, which is unceremoniously known as the finger up the butt test. This is used, in combination, with the PSA blood testing to screen men who may have prostate cancer. When the DRE is performed, the physician is trying to feel for concerning bumps or hard areas in the prostate which may indicate the presence of prostate cancer. Additionally, the finger exam will try to assess how big the prostate is as this can also help to interpret the value of the PSA.
I heard that checking my PSA is inappropriate, is that true?
Full disclosure here!!!!!! I am a urologist and my response is biased based on what kind of doctor I am and my overall experience in taking care of patients. My answer is yes that it can be helpful for the right patient. My answer also includes that you need an honest urologist to interpret this to make sure you do not go through any unnecessary procedures or testing. Routine PSA testing has its pros and cons. There is a LOT of controversy and debates surrounding the benefit of screening men for prostate cancer using this blood test. To be clear, I am talking about routine screening and not for following men who already have a diagnosis of prostate cancer.
The benefit of PSA screening depends on your age and your overall life expectancy. What does this mean? If your life expectancy is short then there is no real benefit for routinely having a PSA checked. The reason for this is that you will likely pass away or having bothersome symptoms from causes other than prostate cancer. Additionally, if you are a younger male, there is no benefit because the likelihood of prostate cancer is super duper low.
All right, all right I can see you have a career in politics. Give it to me straight, should I or shouldn’t I have my PSA checked?
Well…let’s walk through who may benefit from screening. In my practice, I will tell men that I find benefit if you are between the ages of 55-70. I may recommend screening at a younger age if you have a family history (dad, brother, etc) of prostate cancer. After the age of 70, I will really look closely at your overall health. For most men, at this point I think the risk benefit is low and we can stop. For some men who are very healthy overall then there may be instances where your predicted life expectancy may show that continuing screening is reasonable. The reason that we are checking the PSA for these men is that we are trying to diagnose men with real deal prostate cancer that with intervention, we can improve their quality of life as well as their overall survival.
Now, how frequently you need your PSA checked is very dependent on the actual number of the PSA. For some men, they will benefit from having it checked every year. For other men, the frequency can sometimes be pushed out to every 2-3 years.
It used to be that the United States Preventative Task Force (USPTF) recommended against PSA screening. This task force is designed to look at certain medical interventions and weigh in on if there is a benefit to doing a particular test or not. For example, the task force does recommend screening colonoscopies beginning at the age of 50. As urologists got better at decreasing the harms of testing an elevated PSA as well as treating prostate cancer overall, the recommendation has changed. Now the recommendation is to selectively offer this service to individuals based on professional judgement and patient preferences and that there is at least moderate certainty that the net benefit with screening is small. Again this is one governing body and there are others to do find a benefit (when properly done) to have the blood test checked.
If it’s just a blood test, then what is the harm of having this tested?
There is no free lunch in medicine. The harm in testing is going through tests and evaluation, and the possible risks of those additional test, when it is potentially unnecessary to do so. Remember, PSA stands for prostate-specific antigen, not prostate cancer specific antigen. There are other things—infection, trauma, enlarged prostate—that can cause a PSA elevation. Additionally, for some men the risks associated with low-risk prostate cancer are so low that you might be better off if we didn’t find it. The workup for an abnormal PSA is not necessarily easy and can have potential risks. This is why it’s really important to understand why and when you should have your PSA tested as well as to really understand whether a workup truly is indicated if you are told that you have an elevated PSA.
So what tests are recommended for an elevated PSA?
The traditional evaluation for an abnormal PSA is a prostate biopsy. This is usually performed in the urologist office and will take 5-10 minutes. An ultrasound probe is placed into the rectum to help take images of the prostate. Using these images will allow us to sample various locations in the prostate where prostate cancer typically lives. Even though this is a short procedure, it isn’t very comfortable which goes back to why I am very particular about who I recommend PSA testing.
What are the risks of a prostate biopsy?
There are several symptoms that happen almost uniformly, and temporarily, after a prostate biopsy. You will see some blood when you pee as well as when you poop on average for about 3-5 days. If you have sex or masturbate, your ejaculate will look brownish or reddish usually for up to a month. Safe to do both, just know that the color will be alarming if you weren’t expecting this.
The most serious risk is getting an infection. This risk in my hands is now about 1-2% however in some series that risk is as high as 3-4%. This infection can range from a simple urinary tract infection (UTI) to full blown sepsis requiring admission to the hospital and potentially the ICU. Thankfully this is risk is low but there are several measures that I will take to reduce this risk. Prior to the biopsy you will do an enema at home to clear out the rectum as best as possible. Additionally, you will be given antibiotics to take prior to the procedure as well.
Is there any other way to evaluate an elevated PSA?
One of the newer ways to check is to get a prostate MRI. This is very new to prostate cancer evaluation and as time has gone on, urologists and radiologists are getting more comfortable in interpreting this test. When I say new, I mean over the last 5-10 years we are getting more advanced at performing and interpreting this test. The MRI here is done under a very specific protocol and will look to see if there are any lesions, or spots, in the prostate that are concerning. A lesion doesn’t mean there is cancer there, it just tries to quantify the likelihood of prostate cancer. If there is a concerning lesion, your urologist will want to evaluate further with a prostate biopsy (sometimes the MRI images will be connected to the ultrasound machine in what is called a fusion biopsy). Getting a MRI for evaluation of an elevated PSA may or may not be covered by insurance, which is why frequently we will proceed with a prostate biopsy first.
Ok I am kind of getting the picture, but let’s go back for a second, what PSA value is abnormal?
You may be right, I should probably run for office or become a lawyer because the answer again is that it depends. First off, this answer is for people who have never received treatment for prostate cancer, it is just for evaluating a PSA in someone who is undergoing screening. In my opinion, these are the most important factors that come into play when interpreting a PSA: age, size of the prostate, prior PSAs, family history, and race. The older you are, the higher we can expect the PSA to be. If you have more prostate tissue, your prostate will produce more PSA. Remember, an enlarged prostate is not the same as prostate cancer. If the PSA jumps, meaning more than 0.75 per year, then this may be a concerning change. Lastly, Black men have not only a higher risk of prostate cancer but also of high-risk disease and as such I am more aggressive in monitoring them.
Depending on those above factors, a PSA higher than 2.5 or 4 would be considered abnormal. So when I am looking at the number, I will take into consideration all the other factors to say whether I am concerned at all at a lower level or not.
So...my doctor says my PSA is abnormal, now what?
First off, ask if your prostate exam is abnormal. If your prostate exam or DRE is abnormal, then that means that you need to get a biopsy. If your exam is normal, I would ask to have the level repeated. I have seen numerous times that when we recheck the value, it is actually normal and no testing is needed. In my experience, many urologists don’t recheck the PSA and that may be inappropriate.
Now if everything is confirmed to be abnormal, then I would recommend proceeding with the prostate biopsy. For more information about this, you can read my prostate biopsy interpretation post over here or learn what the NIH has to say about an elevated PSA over here.