From the Guidelines
A PSA increase from 2.1 to 3.4 over one year in a 72-year-old male with a previous PSA of 3.9 is significant and warrants medical evaluation. This rise should be discussed with a healthcare provider promptly, as it represents a significant relative increase (approximately 62%) that exceeds the generally accepted threshold of concern (0.75 ng/mL per year) 1. While this PSA level remains below the traditional 4.0 ng/mL cutoff, the rate of change is more concerning than the absolute value. The evaluation would typically include a detailed medical history, physical examination including digital rectal exam, and possibly additional testing such as a free PSA test, PSA density calculation, or prostate MRI. Various factors could explain this increase, including benign prostatic hyperplasia, prostatitis, recent ejaculation, or prostate cancer.
Key Considerations
- Age-specific PSA reference ranges suggest that for men 70-79 years old, levels up to 6.5 ng/mL may be considered normal, but the velocity of change remains important regardless of age 1.
- The American Urological Association (AUA) guidelines recommend against routine PSA screening in men over 70 years old, but acknowledge that some men in excellent health may benefit from screening 1.
- The decision to screen or monitor PSA levels in men over 70 should be individualized, taking into account the patient's overall health, life expectancy, and personal preferences.
Next Steps
- The patient should discuss this PSA increase with their healthcare provider to determine the cause and appropriate next steps.
- Additional testing or evaluation may be necessary to determine the cause of the PSA increase and to rule out prostate cancer.
- The patient's healthcare provider should consider the patient's individual risk factors, medical history, and preferences when determining the best course of action.
From the Research
PSA Increase Significance
- A 2.1 to 3.4 PSA increase over 1 year in a 72-year-old male who previously had a PSA of 3.9 may be significant, as studies have shown that an increase in PSA levels can be associated with an increased risk of developing prostate cancer 2.
- According to a retrospective cohort study, patients with PSA levels < 4 ng/mL had a significantly increased risk of developing prostate cancer if the next PSA level increases by approximately 20% 2.
- Another study found that an isolated elevation in PSA level should be confirmed several weeks later before proceeding with further testing, including prostate biopsy, as a high proportion of men with an abnormal PSA finding had a normal PSA finding at 1 or more subsequent visits during 4-year follow-up 3.
- The impact of different PSA testing intervals on Gleason score at diagnosis and the risk of experiencing false-positive biopsy recommendations was evaluated in a population-based cohort study, which found that men with PSA > 1 ng/mL had increased risk of being diagnosed with GS ≥ 7 prostate cancer when screened with longer than annual intervals 4.
Fluctuating PSA Levels
- A study evaluated whether the risk of having a positive repeat prostate biopsy is lower in patients with fluctuating PSA levels than in patients with a steady or steadily increasing PSA level, and found that the risk was no lower in men with a fluctuating PSA level than in those with a steady or steadily increasing PSA level 5.
- However, it is essential to consider that PSA levels can fluctuate due to various factors, and a single PSA test result may not be reliable 3.
Clinical Implications
- The results of these studies suggest that a 2.1 to 3.4 PSA increase over 1 year in a 72-year-old male who previously had a PSA of 3.9 should be carefully evaluated, and further testing, including prostate biopsy, may be necessary to determine the cause of the increase 2, 3, 4.
- Additionally, the use of 5-alpha reductase inhibitors (5-ARIs) has been found to be safe with respect to prostate cancer mortality in the context of regular health care access, and may even reduce the rates of overall and localized disease 6.