PSA 8 ng/mL: Immediate Urology Referral Required
A PSA level of 8 ng/mL mandates immediate urology referral for evaluation of prostate cancer, as this value is double the threshold (>4.0 ng/mL) that requires specialist assessment. 1
Initial Evaluation Before Referral
Before proceeding with invasive workup, exclude conditions that falsely elevate PSA:
- Active urinary tract infection or prostatitis must be ruled out, as these can significantly elevate PSA levels 1
- Recent ejaculation, physical activity, or prostate manipulation (including digital rectal exam) can transiently increase PSA 1
- 5-alpha reductase inhibitors (finasteride, dutasteride) reduce PSA by approximately 50% within 6 months; if the patient is on these medications, the true PSA equivalent would be ~16 ng/mL, making cancer evaluation even more urgent 1
Urologic Workup
The specialist will perform:
- Digital rectal examination to identify palpable abnormalities that may indicate high-risk cancer 1
- Multiparametric MRI before biopsy in most cases, as this has high sensitivity for clinically significant cancer and guides targeted sampling 1
- PSA density calculation (PSA divided by prostate volume on imaging), which is one of the strongest predictors of clinically significant cancer 1
- Prostate biopsy (10-12 core samples) is recommended given PSA >4.0 ng/mL 1
Important Context
Approximately 2 out of 3 men with elevated PSA do not have cancer, but at a PSA of 8 ng/mL, the probability of cancer is substantial enough to warrant thorough investigation 1. The free-to-total PSA ratio has limited utility by itself and should not delay referral 2.