What does a Prostate-Specific Antigen (PSA) level of 28 indicate?

PSA Level of 28 ng/mL: High-Risk Indicator Requiring Urgent Evaluation

A PSA of 28 ng/mL is significantly elevated and indicates a very high probability of prostate cancer (approximately 50% or greater), with substantial risk of metastatic disease requiring immediate urologic referral, prostate biopsy, and staging imaging. 1

Immediate Clinical Significance

• PSA levels above 10 ng/mL are associated with approximately 50% risk of prostate cancer on biopsy, and your level of 28 ng/mL places you well into this high-risk category 1
• At this PSA level, only about 50% of men have pathologically organ-confined disease, meaning there is significant risk the cancer has already spread beyond the prostate 1
• The risk of biochemical recurrence after surgical treatment increases approximately 2-fold for each 2-point increase in PSA level, making your prognosis more guarded if cancer is confirmed 1

Urgent Diagnostic Workup Required

Prostate Biopsy

• Transrectal ultrasound-guided prostate biopsy is mandatory at this PSA level and should be performed urgently 1
• The biopsy should include at least 8-12 cores targeting the peripheral zone to minimize false-negative results 1
• Digital rectal examination (DRE) must be performed to assess for palpable abnormalities, though biopsy is indicated regardless of DRE findings at this PSA level 1

Staging Imaging

• Bone scan is strongly indicated at PSA levels approaching 30-40 ng/mL to evaluate for metastatic disease 2
• One study demonstrated that the frequency of positive bone scans in patients with PSA recurrence after radical prostatectomy was low until levels reached 30-40 ng/mL, and your level of 28 ng/mL approaches this threshold 2
• CT or MRI of the abdomen and pelvis should be considered for staging if prostate cancer is confirmed, particularly if the Gleason score is ≥8 1

Critical Considerations Before Proceeding

Rule Out Confounding Factors

• Verify you are not taking 5α-reductase inhibitors (finasteride, dutasteride), as these medications reduce PSA by approximately 50% after 6-12 months of therapy 3
• If you are taking these medications, your "true" PSA would be approximately double (around 56 ng/mL), making the situation even more urgent 3
• Confirm absence of recent prostate instrumentation, trauma, or ejaculation within the past 48-72 hours, though these factors are unlikely to elevate PSA to 28 ng/mL 1
• Acute prostatitis can elevate PSA, but levels of 28 ng/mL are more consistent with malignancy than infection alone 4

Prognostic Implications If Cancer Is Confirmed

• Recurrence of cancer is evident within 10 years of surgery in approximately 20% of men with preoperative PSA between 2.6-10.0 ng/mL; your risk is substantially higher given your PSA of 28 ng/mL 1
• PSA velocity prior to treatment is associated with risk of prostate cancer death, with PSA velocity >2.0 ng/mL/year indicating approximately 10-fold greater risk of death from prostate cancer in the decade after radical prostatectomy 1
• Integration of clinical stage, histologic tumor grade (Gleason score), and PSA level will be essential for predicting outcomes and determining optimal treatment 1

Common Pitfalls to Avoid

• Do not delay biopsy waiting to "recheck" the PSA—at this level, confirmation is mandatory regardless of repeat testing 1
• Do not assume benign prostatic hyperplasia (BPH) is the cause; while BPH can elevate PSA, levels of 28 ng/mL strongly suggest malignancy 4
• Do not rely on free/total PSA ratio at this level—this test is useful in the diagnostic "gray zone" of 4-10 ng/mL but is not indicated when PSA is this markedly elevated 1, 4
• Bone scans are generally not necessary with PSA <20 ng/mL, but your level of 28 ng/mL warrants imaging given the proximity to the 30-40 ng/mL threshold where metastases become more common 2, 1