What does an elevated Prostate-Specific Antigen (PSA) level indicate?

From the Guidelines

An elevated Prostate-Specific Antigen (PSA) level of 28.21 ng/ml indicates a high possibility of prostate abnormalities, including prostate cancer, and warrants further investigation. The PSA level is a screening tool, not a definitive diagnostic test, and can be elevated due to various conditions such as benign prostatic hyperplasia (BPH), prostatitis, recent ejaculation, or prostate trauma 1. The higher the PSA level, the more concerning it may be, and age-specific reference ranges exist since PSA naturally increases with age. According to the study by Thompson et al, as cited in 1, at a PSA level of 3.1 ng/mL, the sensitivity is about 32% and the specificity is about 87% for detecting any prostate cancer. However, with a PSA level of 28.21 ng/ml, the risk of prostate cancer is significantly higher, and additional testing such as a digital rectal exam, prostate MRI, or possibly a prostate biopsy should be considered to determine the cause 1. It's also important to consider PSA velocity and PSA density, as well as other factors such as family history, ethnicity, and prior biopsy history, in the interpretation of PSA results 1. Regular monitoring of PSA levels is crucial for men over 50, or earlier for those with risk factors like family history of prostate cancer or African ancestry. In this case, with a significantly elevated PSA level, prompt further evaluation and consultation with a healthcare provider is essential to determine the underlying cause and appropriate course of action.

From the FDA Drug Label

Dutasteride reduces serum prostate-specific antigen (PSA) concentration by approximately 50%. However, any confirmed increase in PSA while on dutasteride capsules may signal the presence of prostate cancer and should be evaluated, even if those values are still within the normal range for untreated men.

An elevated Prostate-Specific Antigen (PSA) level of 28.21 ng/ml may indicate prostate cancer or other prostate problems. However, it's essential to consider that dutasteride can reduce PSA levels by approximately 50%. Therefore, any confirmed increase in PSA while on dutasteride should be evaluated by a healthcare provider, even if the values are still within the normal range for untreated men 2.

From the Research

Elevated Prostate-Specific Antigen (PSA) Level

An elevated Prostate-Specific Antigen (PSA) level can indicate several conditions, including prostate cancer, benign prostatic hyperplasia, and prostatitis.

• A PSA level of 28.21 ng/ml is considered elevated, as the normal range is typically below 4 ng/ml 3.
• The specificity of a PSA level in the diagnosis of prostate cancer increases with higher PSA levels, with a specificity of 87.5% for PSA levels between 20.1-50 ng/mL and 98.2% for PSA levels between 50.1-100 ng/mL 4.
• However, an elevated PSA level does not necessarily mean that a person has prostate cancer, as other conditions can also cause an increase in PSA levels.

Diagnostic Performance of PSA Level

The diagnostic performance of PSA level in detecting prostate cancer has been evaluated in several studies.

• A study found that the area under the receiver operating characteristic curve (AuROC) for PSA level in detecting prostate cancer was 0.82, indicating good diagnostic performance 4.
• Another study found that repeating the measurement of PSA in symptomatic men can avoid unnecessary prostatic biopsy, as a normal repeat PSA level can indicate a low risk of prostate cancer 5.

Role of Digital Rectal Examination (DRE) in Prostate Cancer Diagnosis

Digital rectal examination (DRE) is also used in the diagnosis of prostate cancer, but its role has been limited by the widespread adoption of MRI and PSA measurements.

• A study found that DRE alone would have missed 40% of prostate cancers, while PSA alone would have missed only 1 of the 10 cancers 3.
• Another study discussed the limited role of DRE in the modern prostate cancer diagnostic pathway, particularly in the COVID-19 era 6.

Detection of Prostate Cancer

The detection of prostate cancer using PSA level and DRE has been evaluated in several studies.

• A study found that the combined use of DRE and PSA testing affords a more complete evaluation of the prostate gland for malignant involvement 3.
• Another study found that PSA measurement had a greater sensitivity than prostatic acid phosphatase (PAP) measurement in detecting prostate cancer 7.