From the Guidelines
A PSA level of 5.9 ng/mL warrants immediate urological evaluation due to its elevation above the traditional cutoff of 4.0 ng/mL, which may indicate prostate cancer or other prostate-related conditions. According to the NCCN clinical practice guidelines in oncology: prostate cancer early detection 1, most doctors agree that men with PSA levels greater than 4 should undergo further testing, such as a prostate biopsy, to look for prostate cancer.
Key considerations in the evaluation of a PSA level of 5.9 ng/mL include:
- The patient's age, as prostate cancer risk increases with age
- Family history, particularly if first-degree relatives have been diagnosed with prostate cancer
- Prior PSA values, if available, to assess the rate of change
- Other risk factors, such as ethnicity, with African-American men having a higher risk
The urologist will likely perform a digital rectal examination (DRE) and may recommend additional testing, such as:
- Free PSA test to help differentiate between prostate cancer and benign conditions
- PSA density calculation to assess the likelihood of cancer
- Prostate MRI to visualize the prostate gland and guide potential biopsies
- Prostate biopsy, which is the definitive test for diagnosing prostate cancer
It is essential to note that an elevated PSA does not necessarily mean prostate cancer is present, as other conditions like prostatitis or benign prostatic hyperplasia (BPH) can also cause PSA elevations 1. However, timely evaluation of elevated PSA levels is crucial for proper diagnosis and management of any underlying conditions, and delaying evaluation is not recommended.
From the Research
Prostate-Specific Antigen (PSA) Level and Urology Evaluation
- A PSA level of 5.9 may warrant urology evaluation, as studies have shown that PSA levels above 4 μg/L can indicate an increased risk of prostate cancer 2, 3.
- The combination of digital rectal examination (DRE) and PSA testing provides a more complete evaluation of the prostate gland for malignant involvement 2, 3.
- A study published in 2017 found that PSA detected significantly more tumors (82%) than DRE (55%), and the cancer detection rate was 4.6% for PSA and 3.2% for DRE 3.
- Another study published in 2024 found that DRE improved the effectiveness of an opportunistic significant prostate cancer-screening program, with a specificity of 52.8% and 38.7% with and without DRE findings, respectively 4.
Diagnostic Accuracy of PSA and DRE
- A systematic review and meta-analysis published in 2024 found that the positive predictive value (PPV) of DRE was 0.21, similar to the PPV of PSA (0.22), but the cancer detection rate (CDR) of DRE was significantly lower than that of PSA (0.01 vs 0.03) 5.
- The study also found that the combination of DRE and PSA did not significantly improve the CDR or PPV compared to PSA alone 5.
- A study published in 2025 found that the combination of PI-RADS v2.1 scores with prostate-specific antigen density (PSAD) increased diagnostic accuracy for the detection of prostate cancer, with a sensitivity of 96.97% and specificity of 71.43% 6.
Urology Evaluation Recommendations
- Based on the studies, a PSA level of 5.9 may warrant urology evaluation, including DRE and possibly other diagnostic tests such as transrectal ultrasonography (TRUS) or multiparametric magnetic resonance imaging (mp-MRI) 2, 3, 6.
- The decision to perform a biopsy should be based on a combination of factors, including PSA level, DRE findings, and other diagnostic test results 3, 6.