Ask These Questions if Your PSA Is High

If a guy goes in for a prostate-specific antigen (PSA) test and the results come back showing elevated levels, it can indicate cancer. But not always.

PSA levels can be elevated for other reasons, so the best way to map out what lies ahead is to ask questions.

First, a little background. The prostate-specific antigen is a protein produced by the prostate gland that can be measured by a blood test, according to Harras Zaid, M.D., a urologist and urologic oncologist based in Texas at Urology Austin. But the test has inherent limitations, and a slightly elevated PSA level does not necessarily indicate the presence of prostate cancer. Abnormal PSA test results can, however, trigger additional tests to evaluate a patient's risk.

That's true even if the primary purpose of a PSA test is to screen for prostate cancer, confirmed David Lee, M.D., a professor of clinical urology at UCI Health in Irvine, California. When someone's PSA level goes above a certain threshold—greater than 4 nanograms per milliliter (ng/mL)—there's often reason to be concerned about cancer.

"When a guy has an elevated PSA, we're thinking that guy has a higher risk of having prostate cancer, and then prostate cancer, in general, is the most commonly diagnosed cancer in men," Lee said. "It's the second-highest death rate as far as cancer-specific mortality per year in the United States, after lung cancer."

Not all primary care doctors order the PSA test for male patients. It's a documented lifesaver, but it has also led to many unnecessary biopsies. In 2018, the U.S. Preventive Services Task Force revised previous recommendations that had stated the potential harms of PSA-based screening outweighed the benefits. Subsequent research increased the task force's certainty about the reduction in risk of death due to prostate cancer with PSA testing, hence, the revision.

Lee said men without a family history of the disease and without known risk factors should usually have PSA tests conducted annually between the ages of 55 and 69. He said it's reasonable for guys with a family history of prostate cancer and for men of African American descent, who are at greater risk of developing the disease, to start annual PSA screening around age 40.

Questions to ask if your PSA levels are high

If a guy finds out his PSA levels are elevated, there are several questions he can ask his doctor to help him understand what's going on. Even before that, though, Lee suggested it's appropriate for men who've reached age 55—or 40 if they have the relevant risk factors—to ask their doctor about adding a PSA-based screening to the mix when a battery of blood tests is being ordered.

Zaid suggested one way to frame the pertinent question: "Is PSA screening appropriate for me based on my age and other health conditions?"

"Not all men are good candidates for prostate cancer screening and the PSA blood test," he added. "For example, men with limited life expectancy, multiple other medical problems or advanced age may not benefit from PSA screening, as their other health issues are more likely to create a problem than a potential prostate cancer."

In addition, it's appropriate to ask, "Should my PSA level be rechecked?" Zaid mentioned this question because approximately 30 percent of men can have a PSA test result that significantly decreases when a follow-up blood test is done without intervention within three to four weeks.

A related question Lee suggested someone might also ask at this stage: "Is a biopsy needed?"

A biopsy is not always obligatory.

"These men may be spared additional evaluation and anxiety," Zaid explained. "As such, most men should have a confirmatory PSA blood test."

If a confirmatory test corroborates high PSA levels, Zaid said patients still have yet another question they should ask: "What other tests might be used to evaluate prostate cancer risk, short of a biopsy?"

A percent-free PSA blood test, which measures PSA that is not attached to other proteins, can be added, as can magnetic resonance imaging (MRI) to obtain high-quality pictures of the prostate. Those images can be examined for potentially concerning parts of the gland and to identify what areas might be specifically targeted by a biopsy.

"If an MRI scan is reassuring and a [digital rectal exam] is reassuring, some men can be monitored with a follow-up PSA in three to six months," Zaid said. "This is especially true for men who have a larger prostate that may be driving the elevated PSA."

The prostate MRI has come a long way in terms of accurately detecting cancer, Lee said, and specific changes in the MRI signal can aid a radiologist in determining whether cancer is present. If the radiologist sees a suspicious-looking area, that part of the prostate can be assessed on a scale of 1 to 5 (with 5 being clinically significant cancer) using the Prostate Imaging Reporting & Data System (PI-RADS). The MRI also reveals the size of the prostate, which can help a doctor decide if a biopsy is necessary.

"The only way to know for sure whether there's cancer in there or not is by actually taking tissue out of the prostate, and we usually do that through a prostate biopsy," Lee said. "But before somebody gets to that point of doing a prostate biopsy, there are several tests that we can do."

The Prostate Health Index (PHI) and the 4Kscore blood test offer additional information, according to Lee, who said he also likes to order an ExoDX test, which requires a urine sample. The sample is then sent to a company that runs a test that looks for prostate cells, and DNA can be extracted from those cells to determine the chances the patient may have cancer.

He said asking about the deadliness of any diagnosed prostate cancer also makes sense—"Just how dangerous is my cancer?"—however, your primary care physician might not be able to provide a definitive answer and a referral to a urologist who can better address the question might be in order, he added.

Zaid said if you are diagnosed with prostate cancer, you should ask, "Is treatment necessary?"—it isn't in every case.

"In fact, many prostate cancers are indolent, meaning they will never create an issue and can and should be observed, since they do not pose a known harm," Zaid said. "A number of men will be diagnosed with prostate cancer that should be watched, not treated, as the risks/harms of treatment outweigh the risks/harms of the cancer itself."

Additional prostate-specific considerations

If a biopsy is required, Lee said there are now ways to do one without having to go through the rectum. Patients should ask, "What are my surgical options?"

"There's something called a transperineal biopsy that's available at some centers where the needles can be placed into the prostate through the skin between the scrotum and the rectum," he said. "The ultrasound will still go in the prostate to guide the needle, but then, by not putting the needle through the rectal wall, you can turn the complication rate of infection with a prostate biopsy to zero."

Robotic surgery—an area in which Lee specializes—also enables greater accuracy and provides better treatment outcomes for men with prostate cancer.

Localized prostate cancer tends to progress slowly, Zaid noted.

"Even when a localized prostate cancer is felt to be 'significant' and warrants treatment, patients should make sure they take the time to seek out all options before making a decision," he explained. "Waiting a few weeks, even a few months, to make a treatment decision is unlikely to change one's outcome."

He also recommended the American Urological Association's resources on prostate health.