When most patients receive a PSA test, they are unaware of the history of this test that has transformed it from one of the least reliable tests in medicine to arguably one of the most useful. We always try to educate our patients about PSA testing as it is an easy tool for them to understand, even as a patient. Historically, a single PSA measurement was used to order a biopsy for prostate cancer. If the PSA is above four, we will do a biopsy. If we found cancer, it would be treated – often aggressively.
We quickly realized that this was not a great way to diagnose and treat prostate cancer patients because most prostate cancers grow slowly and many do not need treatments in their early stages. From this, we developed what is known as PSA velocity. Does the PSA rise relatively quickly over a short period of time? If so, we’ll do a biopsy. if not, we wait and watch. But even that had its limitations, as many urologists biopsied candidates with an elevated PSA, even if their reading was low—say around two. From there, we added more modifiers, including PSA density, which represents other characteristics that may increase PSA. Today, PSA is a key tool used as a first-line diagnostic in our prostate cancer practice.
The three factors that can raise PSA
When discussing PSA, most people go directly to prostate cancer. A high PSA equals a chance of prostate cancer. However, this is not always true, although the main factor in rapidly rising PSA is, indeed, malignancy. As mentioned above, the PSA no longer reads as a single event. Instead, we use a trend line to see if cancer might be present. We may see PSA rise from 3 to 3.5 to 4 to 4.4 and higher for many years. Of course, this can happen even faster. At this point, trend and modifying factors tell us when a biopsy is likely the right next step.
Age
With the complexity and understanding of PSA, we also know that age is an important factor for PSA. Older men have a higher PSA, all other things being equal. Therefore, we must use our best judgment to understand if the higher PSA trend is due to this irreversible cause or if there is an underlying malignancy.
BPH
Benign prostatic hyperplasia, or BPH, is another cause of elevated PSA. We’ve done a lot of research on this topic and have a good idea of differentiating BPH-related PSA elevations from cancer-related issues. It is also important to remember that symptoms associated with BPH are rarely shared with prostate cancer, so if you are experiencing lower urinary tract symptoms, we encourage you to see Dr. Natale and be assured that the possibility is benign.
Prostatitis
An infection in the prostate, such as BPH, can cause PSA levels to rise.
While these are all non-cancerous reasons for an elevated PSA and none necessarily lead to prostate cancer, prostate cancer can coexist with benign conditions. We recommend seeing a qualified urologist and men’s health specialist for a definitive diagnosis.
Next steps
Once the PSA trend is read and if malignancy is suspected, we work with our physicians to send a biopsy of prostate tissue to our lab. These specialized professionals send back the pathology results to give us a better idea of what the cancer is. This usually comes with a Gleason score, which we explain on our blog here.
In some cases, a prostate MRI may be ordered, although this is by no means a surefire next step. MRI of the prostate can be useful in a narrow set of circumstances to understand more about the tumor and any spread that may have occurred to surrounding structures and lymph nodes.
Ultimately, Dr. Natale and his patient decide exactly how to proceed. This may include watchful waiting if we think the prostate cancer is growing slowly. Some patients with more aggressive cancers may need a prostatectomy, which involves removing the prostate. This is a simple procedure, but even nerve-sparing prostatectomies have a relatively long recovery process, which Dr. Natale will explain during the consultation.
We encourage you to contact Dr. Natale for your regular checkup and prostate exam if you are experiencing lower urinary tract symptoms. From treating BPH or enlarged prostate to prostate cancer, Dr. Natale offers his patients a full range of services and treatments to maintain and improve prostate health.
