From the Guidelines
If your PSA level is elevated, I strongly recommend consulting with a urologist promptly for proper evaluation, as the benefits of early detection and treatment may outweigh the harms of screening, especially for men between 50 and 69 years old 1. An elevated PSA doesn't necessarily mean cancer but requires investigation. Your doctor will likely recommend additional testing, which may include a digital rectal exam, PSA velocity assessment (measuring how quickly PSA levels change over time), free PSA percentage, and possibly advanced tests like the 4Kscore or prostate MRI. If these results suggest concern, a prostate biopsy may be necessary. While waiting for your appointment, avoid activities that can artificially raise PSA levels, such as ejaculation within 48 hours before testing, vigorous exercise, or prostate manipulation. Certain medications like finasteride (Proscar) or dutasteride (Avodart) can affect PSA readings, so inform your doctor if you're taking these. PSA elevation can result from various conditions including prostate cancer, benign prostatic hyperplasia (BPH), prostatitis (inflammation), or recent urinary tract infections. The threshold for concern varies by age, with higher baseline levels considered normal in older men. Some key points to consider when evaluating PSA levels include:
- The American College of Physicians recommends that clinicians inform men between the age of 50 and 69 years about the limited potential benefits and substantial harms of screening for prostate cancer 1.
- The USPSTF recommends against screening for prostate cancer in men who do not express a clear preference for screening 1.
- Men with a life expectancy of less than 10 to 15 years should not be screened for prostate cancer using the prostate-specific antigen test 1.
- High-risk patients, such as those with a family history of prostate cancer, should receive information about the uncertainties, risks, and potential benefits associated with prostate cancer screening beginning at age 45 years 1. Remember that PSA is just one screening tool, and proper interpretation requires professional medical evaluation. It's also important to note that the decision to screen for prostate cancer should be based on a shared decision-making approach, taking into account the patient's values, preferences, and individual risk factors 1.
From the Research
Elevated PSA Recommendations
- For men with rising PSA levels after prostatectomy, imaging studies such as pelvic MRI, transrectal US, CT, PET/CT, and PET/MRI may be obtained to localize disease 2
- A raised PSA may indicate biochemical recurrence and often the need for further therapy, with three monthly PSA measurement usually recommended for the first year after primary treatment 3
- The US Preventive Services Task Force recommends that the decision to undergo periodic PSA-based screening for prostate cancer should be an individual one and should include discussion of the potential benefits and harms of screening with their clinician, for men aged 55 to 69 years 4
Diagnostic Pathway
- Digital rectal examination (DRE) is routinely performed as part of a urology clinical assessment in patients with a clinical suspicion of prostate cancer, but its role is limited in the modern prostate cancer diagnostic pathway due to the widespread adoption of MRI 5
- The use of DRE in prostate cancer screening is under scrutiny, with recent studies reaffirming its sensitivity and specificity, but also highlighting its limitations and the potential of MRI as a superior screening tool 6
Imaging Studies
- Pelvic MRI and transrectal US are commonly used to evaluate local disease recurrence after prostatectomy 2
- CT can evaluate for lymph node metastasis, but is suboptimal in the evaluation of the prostatectomy bed 2
- PET/CT and PET/MRI have been used successfully to evaluate for local disease recurrence 2