What is the significance of a Prostate-Specific Antigen (PSA) level of 5 in a 63-year-old male without symptoms?

From the Guidelines

For a 63-year-old male with a PSA of 5 ng/mL without symptoms, I strongly recommend a referral to a urologist for further evaluation, as this PSA level is above the typical normal range and warrants additional assessment, even in the absence of symptoms, according to the most recent guidelines 1. The patient's PSA level of 5 ng/mL is above the typical normal range of 0-4 ng/mL, which suggests the need for further evaluation. The urologist will likely perform a digital rectal examination (DRE) to check for prostate abnormalities and may recommend additional PSA testing to confirm the elevation. Some key points to consider in the evaluation process include:

• The patient's age and PSA level, which are both risk factors for prostate cancer 1
• The potential for benign prostatic hyperplasia (BPH), prostatitis, or recent ejaculation to cause an elevated PSA level 1
• The importance of avoiding activities that might artificially raise PSA levels, such as bicycle riding, ejaculation, or prostate manipulation, for 48 hours before any follow-up PSA test
• The need for the patient to inform the urologist about any medications he's taking, particularly 5-alpha reductase inhibitors like finasteride or dutasteride, which can affect PSA levels 1 If the PSA remains elevated, the next step would typically be a multiparametric MRI of the prostate and/or a prostate biopsy to rule out prostate cancer. It's also important to note that an elevated PSA doesn't necessarily indicate cancer, and a thorough evaluation by a urologist is necessary to determine the cause of the elevated PSA level. The patient's overall health and medical history should also be taken into consideration when determining the best course of action, as recommended by the American Cancer Society guidelines 1.

From the FDA Drug Label

1. 1 Effects on Prostate Specific Antigen (PSA) and the Use of PSA in Prostate Cancer Detection In clinical studies, finasteride tablets reduced serum PSA concentration by approximately 50% within six months of treatment. To interpret an isolated PSA value in patients treated with finasteride tablets for six months or more, PSA values should be doubled for comparison with normal ranges in untreated men.

For a 63-year-old male with a PSA of 5 without symptoms, if he were to be treated with finasteride, his PSA value would need to be doubled to compare with normal ranges in untreated men. Therefore, his adjusted PSA value would be 10.

• Key consideration: Any confirmed increase from the lowest PSA value while on finasteride tablets may signal the presence of prostate cancer and should be evaluated, even if PSA levels are still within the normal range for men not taking a 5α-reductase inhibitor 2.

From the Research

Prostate Cancer Detection and 5-Alpha Reductase Inhibitors

• A 63-year-old male with a PSA of 5 without symptoms may be considered for 5-alpha reductase inhibitor (5-ARI) treatment to reduce prostate cancer risk 3.
• Studies have shown that 5-ARIs can reduce prostate cancer risk, but may increase the risk of high-grade disease in men undergoing regular screening using prostate-specific antigen and digital rectal examination 3.
• The effect of 5-ARIs on magnetic resonance imaging (MRI) and prostate cancer detection is still being researched, with some studies suggesting that 5-ARI exposure does not change the PI-RADS distribution and the clinically significant prostate cancer detection rates 4.

5-Alpha Reductase Inhibitors and Prostate Cancer Mortality

• A study found that men taking 5-ARIs with regular health care access do not have increased prostate cancer mortality, and may even have reduced rates of overall and localized disease 5.
• Another study suggested that 5-ARI use is safe with respect to prostate cancer mortality in the context of regular health care access, and may reduce the risk of low-risk prostate cancer diagnosis 5.

5-Alpha Reductase Inhibitors and MRI Findings

• Research has shown that 5-ARI treatment can alter lesion MRI characteristics and PI-RADS distribution on MRI, which should be reported to the radiologist 6.
• A study found that 5-ARI intake may increase the sensitivity and decrease the specificity of MRI findings in patients with suspected prostate cancer 6.
• The impact of 5-ARIs on MRI findings and prostate cancer detection is still being studied, with some research suggesting that 5-ARI use may confound MRI findings and reduce the rate of positive biopsies 7.