Management of 1-Point PSA Increase Over One Year
A 1-point PSA increase over one year requires immediate referral to urology for further evaluation, as this rate of rise meets established thresholds for significant PSA velocity regardless of the absolute PSA value. 1, 2
Immediate Action Required
Refer to urology without delay. The American College of Physicians specifically recommends referral for PSA increases of 1.0 ng/mL or more in a year, regardless of baseline value. 1, 2 This threshold is based on evidence that such velocity changes signal potential prostate cancer even when absolute PSA remains in the "normal" range. 2
Clinical Context Matters
If Patient is on Testosterone Replacement Therapy (TRT)
- Prostate biopsy is specifically indicated for men on TRT with yearly PSA increases of 1.0 ng/mL or more. 1
- The typical PSA increase with TRT is only 0.30-0.43 ng/mL, making a 1-point rise substantially abnormal and concerning for malignancy. 1
- Men with family history of prostate cancer should have an even lower threshold for biopsy while on TRT. 1
If Patient is on 5-Alpha Reductase Inhibitors (Finasteride/Dutasteride)
- Any confirmed increase from the lowest PSA value while on these medications may signal prostate cancer and requires evaluation, even if PSA levels remain within normal range for untreated men. 3, 4
- These medications reduce PSA by approximately 50% within 3-6 months of treatment. 3, 4
- A rising PSA despite these medications is particularly concerning and warrants urgent referral. 3, 4
Post-Treatment Surveillance Context
After Radical Prostatectomy
- Any confirmed detectable PSA after surgery warrants referral to the treating specialist, as PSA should drop to undetectable levels (<0.03 ng/mL) within 2 months. 5
- A 1-point increase in this setting represents clear biochemical recurrence. 5
After Radiation Therapy
- PSA falls slowly after radiation and reaches its nadir after 6 months to several years. 5
- A 1-point rise from nadir requires specialist evaluation for potential recurrence. 5
Surveillance Intervals After Referral
Once the urologist completes initial evaluation and if no cancer is found:
- Measure serum PSA every 6-12 months for the first 5 years, then annually thereafter. 5
- Perform annual digital rectal examination in coordination with the cancer specialist. 5
Critical Pitfalls to Avoid
Do not delay referral based on absolute PSA value. The velocity of change (≥1.0 ng/mL/year) is the critical factor, not whether the absolute value exceeds 4.0 ng/mL. 2 Many clinicians mistakenly wait until PSA crosses traditional thresholds, but significant velocity changes warrant immediate action regardless of baseline. 2
Do not attribute the rise to benign causes without urologic evaluation. While chronic prostatitis can elevate PSA, prostate cancer was still detected in 21.8% of patients with prostatitis and elevated PSA, including 12% of those whose PSA normalized to <2.5 ng/mL after treatment. 6
Do not order repeat PSA to "confirm" the rise before referring. The National Comprehensive Cancer Network recommends repeat PSA in 3-6 months only for increases of 0.7-0.9 ng/mL; a 1.0 ng/mL increase warrants direct referral. 2