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What is PSA?
PSA stands for prostate-specific antigen. It is a protein produced by the cells of the prostate gland. This antigen helps keep the semen liquid so the sperm can swim freely. PSA is usually found in the prostate gland and semen, but small amounts of it can also move into the bloodstream and be measured by a blood test called a PSA test. You can have an elevated PSA if your prostate becomes inflamed for any reason as a result of infection or benign prostatic hyperplasia (BPH).
The PSA test is one of the methods used to detect prostate cancer. Elevated PSA levels may be present in the blood of men who have prostate cancer (although other conditions can cause and elevated PSA as well). The test cannot tell you if a cancer is fast growing or slow to develop. You may also have no symptoms of prostate cancer but still have an elevated PSA.
A PSA test can give you a baseline reading for your prostate health. There has been much controversy over when to get a PSA test and how often because the PSA can indicate many things, from cancer to BPH to prostatitis to other benign conditions. So even if the PSA test doesn’t tell you exactly what it going on, an elevated PSA can clue you in for early detection of an underlying problem. The PSA test is still an important tool to help men determine if something is going on with their prostate health.
The PSA test is also used if you have already been treated for prostate cancer. Watching PSA levels can help your doctor to monitor the effectiveness of treatments such as surgery, radiation, chemotherapy, or hormone therapy, to determine if the therapy is effective, and to chart the progress of the disease before and after treatment. Certain men are in higher-risk groups for getting prostate cancer, and the PSA test can be an important tool for men who fall in a high-risk group.
While there are problems surrounding the PSA test in terms of identifying prostate cancer, what we may need is a paradigm shift in how we look at the PSA. The problem is really rooted in what we want it to be (i.e., we want it to tell us if we do or do not have prostate cancer) when really we need to think of it as an indicator of overall prostate health. Like cholesterol tests and getting blood pressure checked, the PSA test is one of many tests that men should have done to get a complete picture of their health. That is why we are going to break it all down for you here so you and your doctor can make the right health decisions for you based on your health history, genetic make-up, and family history.
Prostate cancer risk factors
The following factors can increase your risk of prostate cancer:
- Age over 65
- Family history
- You are an African-American man
- Lifestyle (unhealthy diet and lack of exercise)
- High Grade “PIN” (irregular cells in the prostate that are pre-cancerous — as determined by a prostate biopsy)
If you have any of these risk factors, it is more important to monitor your PSA.
How do I get my PSA tested?
To have your PSA tested, your doctor will first have you get your blood drawn. There are certain activities that can affect the results, so you want to avoid them before the test. For the 48 hours before the test, you want to avoid vigorous exercise or activities that stimulate or “jostle” the prostate area. Do not ride a bike, motorcycle, horse, ATV, or tractor in the 48 hours leading up to the PSA test. Do not get get a prostatic massage or engage in sexual activity that involves ejaculation for 48 hours before your test. Ejaculation within this time frame may affect PSA results, especially in younger men. A digital rectal examination (DRE) can affect the results of your PSA test, so you want to be sure to schedule your PSA test before you have a DRE.
When to schedule your PSA is also important for accurate results. Do not schedule the test after other medical procedures. Wait to schedule your PSA test to be done at least six weeks after undergoing any of the following procedures: prostate biopsy, transurethral resection of the prostate (TURP), urethral catheter, cystoscopy, or any other procedure that involves the prostate. Any procedures you have recently had will affect your PSA test, so talk to your doctor before scheduling.
Do not schedule a PSA test if you have or have recently had prostatitis or a urinary tract infection. A bacterial infection in the urinary tract can cause PSA levels to rise temporarily. If you are not sure if you have a urinary tract infection, you can have a urine test before your PSA test to make sure. If you do have a urinary tract infection, wait at least six weeks after you have completed your antibiotic treatment before you have your PSA test.
What do I do with results of my PSA test?
You have your results and now what? There are no specific normal or abnormal readings. Traditionally, most doctors considered PSA levels of 4.0 ng/mL and lower as safe. Readings in the 4.0 to 10.0 range are suspicious, and readings greater than 10 are considered dangerous. The American Cancer Society’s guidelines (below) state that men with readings above 2.5 should have their PSA checked annually.
Not all doctors recommend the same PSA cutoff point when discussing with a patient whether to do a biopsy. Some doctors may advise a biopsy if the PSA is 4 or higher, while others might recommend it at 2.5 or higher. Factors such as your age, race, and family history may affect whether your doctor will want to do a biopsy.
The results mean different things for different patients. For example, men who are undergoing “active surveillance” or “watchful waiting,” which is the monitoring of low-risk prostate tumors before getting treatment, may decide to start treatment if their PSA rises more than 0.75 ng/mL each year.
What if my PSA is high?
A high PSA could be caused by many things that are not related to cancer. If you have a high PSA, get follow-up tests to determine cancer, but don’t just rush to get a biopsy, which is often the recommendation from your urologist. First rule out prostatitis, BPH, and other potential causes. Consider “guided MRI” rather than a standard biopsy to determine if there is a malignancy. You can determine if your PSA is naturally high due to causes such as prostate size, sex, bike riding, inflammation, BPH, or prostatitis.
What is the process for getting a prostate biopsy?
If your PSA levels and DRE point to the need of a prostate biopsy, it can be done in your doctor’s office. Your doctor may give you a local anesthetic to make you more comfortable. The doctor will collect samples of your prostate tissue via a hollow needle that may be inserted through the rectum, through the urethra, or through the perineum. It is most commonly done transrectally. An ultrasound probe is inserted in the anus to help guide the procedure. The doctor will take about 8-12 samples. You will hear a clicking sound as the samples are taken and you may experience some discomfort. Your doctor may prescribe an antibiotic to prevent infection.
The good news is that about 80% of men who have biopsies after positive PSA tests find out that they are cancer-free. The bad news is that there is a 3% chance of having a bad infection from it. Having a biopsy can cause stress and anxiety. The most frequent complications of the prostate biopsy include blood in the urine for several days, some blood in the stool for several days, and blood in the ejaculate for several weeks afterwards.
American Urological Association (AUA) Guidelines
The AUA updated its guidelines regarding PSA testing in May 2013. One of the reasons they changed the guidelines was because of the high percentage of negative biopsies. Dr. H. Ballentine Carter stated, “It’s time to reflect on how we screen men for prostate cancer and take a more selective approach in order to maximize benefit and minimize harms.” Keep in mind that these are just guidelines, and you might want to get tested sooner.
The AUA Guidelines:
- Do not recommend PSA screening for men under age 40.
- Do not recommend routine screening for men of average risk between ages 40 to 54 years.
- Recommend shared decision-making for men ages 55 to 69 years who are considering PSA screening, and proceeding based on patients’ values and preferences. For men ages 55 to 69 years, the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality against the known potential harms associated with screening and treatment.
- Prefer a routine screening interval of two years or more over annual screening to preserve the benefits of screening and decrease false positives.
- Routine PSA screening is not recommended in men over age 70 or any man with less than a 10–15 year life expectancy.
These guidelines came about to reduce the harms of screening such as rushing to biopsy healthy tissue and the psychological harms of the patient thinking he has cancer when he does not.
The American Cancer Society’s Guidelines for PSA
The American Cancer Society recommends that men make an informed decision with their doctor about whether to be tested for prostate cancer. The American Cancer Society believes that men should not be tested without learning about the risks and possible benefits of testing and treatment. The patient’s health status, and not age alone, is important when making decisions about screening.
- Starting at age 50, men should talk to a doctor about the pros and cons of testing so they can decide if testing is the right choice for them.
- Starting at age 45, men who are African-American or have a father or brother who had prostate cancer before age 65, should talk with a doctor about screening.
- Starting at age 40 men at even higher risk (those with more than one first-degree relative who had prostate cancer at an early age) should talk to their doctor.
- Because prostate cancer often grows slowly, men without symptoms of prostate cancer who do not have a 10-year life expectancy should not be offered testing since they are not likely to benefit from the results.
The patient and health care provider should take into account the patient’s general health preferences and values in deciding whether to test. After discussing pros and cons, men who want to be screened should be tested with the PSA blood test. The digital rectal exam (DRE) may also be done as a part of screening.
Assuming no prostate cancer is found as a result of screening, the time between future screenings depends on the results of the PSA blood test. What is PSA testing interval recommendations? Here are the American Cancer Society’s recommendations:
- Men who choose to be tested who have a PSA of less than 2.5 ng/ml, may only need to be retested every two years.
- Screening should be done yearly for men whose PSA level is 2.5 ng/ml or higher.
Problems with the PSA test
Some experts argue that the PSA is not that reliable because it can give false positive (indicating cancer that is not there) and false negative (missing prostate cancer that is there) results. In fact, about 80% of the 1.6 million men who have a prostate biopsy in the United States each year because of an elevated PSA level do not have prostate cancer, according to Dr. Robert Getzenberg, MD, director of research at the Brady Urological Institute at Johns Hopkins.
Some cases of prostate cancer, especially those that grow rapidly, also may not produce much of an elevated PSA. This can result in a test result that incorrectly indicates that you don’t have prostate cancer when you do. Overall, the downsides of a PSA test can be boiled down to the following:
- Concern about false-positive results that are caused by elevated PSA levels from something other than prostate cancer;
- Having to undergo invasive, stressful, expensive, or time-consuming follow-up tests such as a prostate biopsy;
- Getting a false-negative result, leading to a missed diagnosis of aggressive prostate cancer that needs treatment;
- Experiencing anxiety or stress caused by knowing you have a slow-growing cancer that doesn’t need treatment; and
- Having surgery, radiation, or other treatments that cause side effects that are more harmful than leaving the cancer untreated.
What does the PSA actually mean?
The simple act of getting a PSA test can result in many different scenarios. That is why it is important to have a doctor with a lot of experience in interpreting PSA results along with any other information gathered from you and other tests as part of your prostate screening decision. What affects PSA? Common factors that can cause a rise in a PSA level include:
- Advancing age
- Prostate biopsy or srugery
- Recent catheterization
- Urinary tract infection
- Urinary tract surgery
- Chemotherapy drugs
- Recent ejaculation and having frequent sex
- Sports supplements taken by athletes (especially body builders) that can cause a rise in testosterone level
- Having a digital rectal exam (DRE) of the prostate
- Riding a bicycle
- Sports injuries
- Pelvic injury or trauma to the prostate
- An enlarged prostate (BPH)
- Prostate cancer
The results of your PSA test are something you and your doctor can use to determine if you are at risk for prostate cancer or other conditions affecting men’s health. Based on the test results, your lifestyle, and family history, you and your doctor can determine what further tests you should get to diagnose, rule out, or change your risk factors for disease or cancer.
Our conclusion: Get the test. Don’t use the medical guidelines as an excuse to avoid a PSA test
A high PSA is the sign of “something” related to your prostate health that may or may not be cancer. Treat your PSA reading as an indicator that your body needs attention. Overall, the “problem” is not the PSA test itself but what happens after the test with the rush to biopsy and aggressively treat what may be a benign disorder. Instead, calmly go forward with less-invasive tests to determine the cause of the high PSA. Ask yourself, “What is my PSA telling me?”
Prostate cancer is the second leading cause of death for American men, and some men are getting prostate cancer as early as their 30s. Ultimately it is your decision whether to get tested. The American Cancer Society and AUA Guidelines are to be used as a guide only and should not prevent you (or not give you an excuse) to delay getting tested at a younger age. An early warning sign of something not being right with your prostate is better than no warning at all, or a warning that is too late. Even though a high PSA may not indicate cancer, it may lead you to focus on better and healthier prostate health habits such as diet, exercise, weight loss, and other lifestyle factors that may reduce the risk of progression to cancer.
Both BPH and prostatitis, which are benign conditions, have links to prostate cancer, so an early warning of reduced prostate health can give you a chance to reduce your overall risk of progression to prostate cancer. Treat your PSA like any other test (cholesterol for heart health, blood sugar for diabetes). It may not be a perfect indicator, but just as high cholesterol can mean you are at risk for a heart attack, your PSA is a message to move towards healthier habits to lower your risk for a variety of conditions.
Don’t use the AUA guidelines as an excuse to avoid a checkup. Think about getting checked in your early 40s or earlier if you are at a higher risk. Get checked, be aware of your numbers, and monitor them as part of any program for healthy living.