What Do Your PSA Test Results Mean, and When Should You Be Concerned?

Key Takeaways

• A PSA test measures blood levels of prostate-specific antigen and can be used to help detect prostate cancer.
• Elevated PSA levels can be related to a person’s health history and lifestyle factors. High PSA levels do not always mean that a man has prostate cancer.
• If a PSA blood test returns abnormal results, further testing may be recommended to determine why PSA levels are elevated.
• A prostate biopsy is the only test that conclusively diagnoses prostate cancer.

What Is a PSA Blood Test?

A PSA test is a blood test that measures the level of prostate-specific antigen in the blood. Antigens are special markers produced by most types of cells. The immune system uses them to identify which substances are threats and which are not. When the immune system recognizes an antigen that belongs in the body, called a “self” antigen, it knows to leave the related cells alone. When it detects an unfamiliar or “non-self” antigen, however, it attacks to destroy the intruder cells.

Prostate-specific antigen (PSA) is a “self” antigen produced by cells in the prostate gland. While both normal and cancerous prostate cells produce PSA, cancerous cells often produce more. This causes PSA levels to rise when cancer is present. By measuring the amount of prostate-specific antigen present in a person’s blood, oncologists can detect the potential presence of prostate cancer.

Who Should Get a PSA Test?

According to recommendations from the American Cancer Society (ACS), most men should begin regular PSA screenings at age 50. This recommendation ensures that men are regularly screened at the period of life when most cases of prostate cancer are diagnosed. The ACS adds that because Black men and men with a strong family history of prostate cancer are at elevated risk for developing the disease early, they should start screening at age 40 or even 45 to improve the likelihood of early detection.

Men can stop screening at age 70 to 75 or when they have a life expectancy of less than 10 years. Most prostate cancers are slow-growing, so early detection and treatment are unlikely to benefit very elderly individuals.

When Are PSA Levels Concerning?

PSA levels are measured in units called nanograms per milliliter (ng/mL). Every man has some PSA, produced naturally by cells in his prostate. Unusually high levels sometimes indicate cancer or another condition of the prostate, such as benign prostatic hyperplasia (BPH).

Normal PSA Levels by Age

To understand when PSA levels are concerning, it is important to know what normal looks like. Age is arguably the most important factor when determining what PSA level is normal. Most men produce more PSA as they get older, so healthy PSA levels increase with age. In general, men should expect their PSA levels to fall within the following ranges per age group:

• Ages 40-49: PSA levels are normally between 0 and 2.5 ng/mL.
• Ages 50-59: PSA levels are normally between 0 and 3.5 ng/mL.
• Ages 60-69: PSA levels are normally between 0 and 4.5 ng/mL.
• Over age 70: PSA levels are normally between 0 and 6.5 ng/mL.

If PSA levels significantly exceed this age threshold, the increased count may indicate cancer – but not always. There are multiple other factors to consider before deciding whether an unusually high PSA number warrants further testing.

What Is PSA Velocity?

When evaluating PSA test results, physicians consider both the current level and the “velocity” of any increase in PSA levels over time. While PSA levels increase naturally over a person’s lifetime, this increase is usually gradual. Very sudden changes are more likely than gradual increases to signify a problem. This is why annual or biannual testing is important. Previous tests provide a baseline for comparison when assessing current PSA levels.

What Is Free PSA vs. Total PSA?

PSA tests also measure the ratio between free and total PSA. Total PSA is the overall quantity of PSA in the blood. Free PSA refers to the amount of PSA that is not attached to blood proteins. Cancer cells tend to bind to proteins more readily than healthy cells, so patients with prostate cancer are more likely to have less free PSA in comparison to their total PSA. Patients with BPH, on the other hand, will have increased PSA levels with a high ratio of free PSA.

What Does an Elevated PSA Mean?

Most men who do not have prostate cancer have PSA levels below 4 ng/mL. If the PSA level is over 4 ng/mL, the PSA is considered elevated. The elevated level sometimes indicates cancer, but it should not be taken as a sure sign that something is wrong. Instead, men should pursue further testing to determine the cause of raised PSA levels and find out whether treatment is necessary.

Other Conditions That Raise PSA

Prostate cancer is not the only condition that increases PSA levels. PSA levels are affected by a wide variety of factors, including prostate conditions, health history, and even lifestyle choices. An increase in PSA may be related to any of the following:

• Vigorous exercise
• Recent ejaculation
• Recent prostate exams or biopsies
• Benign prostate hyperplasia (BPH)
• A prostate or urinary tract infection
• Use of certain drugs that treat BPH

As a result, a high PSA reading should not be taken as a certain sign of cancer. Men who receive an abnormal test result should discuss their recent health history and lifestyle with their physician. If PSA levels are artificially elevated due to recent exercise, ejaculation, or a prostate exam, a follow-up test may be scheduled to confirm the results of the first.

When Do Elevated PSA Levels Likely Mean Cancer?

While a PSA test cannot detect cancer with absolute certainty, there are some test indicators that suggest when cancer is more likely. Abnormal PSA test results are more likely to be related to cancer when:

• PSA levels are over 10 ng/mL
• PSA levels are rising rapidly
• The free-to-total PSA ratio is low

If a man isn’t sure whether his PSA test results are suspicious, n he should ask his physician for clarification. The physician can explain the significance of the PSA level, discuss changes over time, and review any other pertinent test results to help the patient understand the estimated risk of cancer.

What Happens After an Elevated PSA?

If a screening test detects elevated PSA levels, the next step is to find out why the levels are increased. This investigation involves a series of additional tests to confirm the initial results and obtain more information. The typical process is as follows:

Follow-Up PSA Test

The first step after detecting an abnormal PSA level usually is to schedule a follow-up test, especially if the patient has no symptoms of prostate cancer. The follow-up should be performed at least six weeks after the original test. The time gap helps physicians determine whether the elevated reading was temporary or whether the patient’s PSA level is consistently elevated.

Additional Tests

If the follow-up test also shows elevated PSA levels, the physician will request additional testing. The following tests provide extra detail, more precise results, or new data that can be used to determine the likelihood of cancer. Options include:

• 4Kscore test: A 4Kscore test is similar to standard PSA screening, but measures two additional factors to provide more detailed results.
• Prostate health index (PHI): A PHI combines three PSA markers (Total PSA, free PSA, and p2PSA) into a single score that more precisely predicts the probability of cancer.
• Multiparametric magnetic resonance imaging (mpMRI) of the prostate: An mpMRI uses strong magnets to take pictures of the prostate gland. The images are examined to look for cancer tumors or BPH.

When a doctor orders one or more of these tests for a patient, it does not necessarily mean that the patient has cancer. It only means that the physician wants more information. For most patients, the extra testing conclusively rules out cancer as a possibility.

Prostate Biopsy

If prostate cancer is strongly suspected, the physician will order a prostate biopsy. To perform the biopsy, a urologist or other physician uses a thin, hollow needle to remove a small amount of prostate gland tissue. The sample is studied under a microscope in a medical laboratory to check for cancer cells. A prostate biopsy is the only test that conclusively diagnoses prostate cancer.

What Do Prostate Biopsy Results Mean?

Prostate biopsy results are used to diagnose prostate cancer and formulate a treatment plan. By examining cancer samples, oncologists can determine what treatment approach is most appropriate.

What to Expect During the Procedure

A prostate biopsy takes around 10 minutes and is usually painless, although patients may feel a gentle pinch or mild discomfort. It follows these simple steps:

1. The physician injects a local anesthetic to numb the area.
2. The biopsy needle is inserted through the wall of the rectum (transrectal approach) or through the skin between the anus and the scrotum (transperineal approach).
3. Around 12 core samples are taken from different parts of the prostate.

Patients are usually given antibiotics to take before and after the biopsy to reduce the risk of infection. They may experience mild pain, bleeding, or urination difficulties after the procedure, but these side effects should go away within a few days.

What Is a Gleason Score?

If the prostate biopsy finds cancer, the results will be accompanied by a Gleason score. This grading system describes how abnormal the cancer cells look under a microscope. The more mutated the cells are, the more quickly the cancer is likely to spread. Cancer cells are given a Gleason grade from 1 to 5. The two highest-grade samples are added to one another to generate a Gleason score, which can be understood as follows:

• <6: The cancer cells look mostly normal and are unlikely to spread quickly.
• 7: The cancer cells look slightly abnormal and may spread.
• 8-10: The cancer cells look extremely abnormal and are likely to spread aggressively.

Higher Gleason scores usually warrant more aggressive treatment. Cancers with a low score, meanwhile, may not require immediate intervention.

What Is a Grade Group?

Biopsy results also include the grade group. This is a modified version of the Gleason score that is both simpler and more accurate to understand. Grade groups are ranked from 1 to 5, with Grade 1 cancers being the least aggressive and Grade 5 cancers being the most aggressive.

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If you have received a diagnosis of prostate cancer, you should look for the best quality of care you can access. Regional Cancer Care Associates (RCCA) offers advanced prostate cancer care at more than 20 locations near you across New Jersey, Connecticut, Massachusetts, and the Washington, D.C., area. Contact RCCA today to learn more about treatment options or to schedule a consultation.

Frequently Asked Questions About PSA Tests and Prostate Cancer

Does an elevated PSA always mean cancer?

No, an elevated PSA level does not always mean cancer. While increased PSA can be caused by prostate cancer, it may also relate to benign prostatic hyperplasia (BPH), a prostate infection, a recent prostate biopsy, or lifestyle factors, such as rigorous exercise or recent ejaculation.

What conditions other than cancer can raise PSA?

Conditions that can raise PSA include benign prostatic hyperplasia (BPH), a prostate or urinary tract infection, or use of certain medicines that increase PSA levels artificially.

What happens after an abnormal PSA result?

After getting an abnormal PSA test result, further testing usually is recommended. Additional tests help determine why the PSA levels are elevated to either confirm or rule out cancer as a possibility.

At what age should I start prostate cancer screening?

Most men should start prostate cancer screening at age 50. Black men and men with a strong family history of prostate cancer should start at age 45 or 40.

How often should I get a PSA test?

Most men should get PSA tests every two years between age 50 and age 70-75. Patients with a higher-than-average risk of prostate cancer, such as those who have a strong family history of prostate cancer, should get PSA tests annually.

What is a free PSA test?

A test of free PSA measures the amount of prostate-specific antigen in the blood that is not attached to a cell or protein. It helps physicians determine whether elevated PSA levels are caused by prostate cancer or by benign prostatic hyperplasia (BPH).

How accurate is the PSA test?

The PSA test is very accurate at measuring PSA levels and can detect the possibility of cancer before symptoms develop. Even so, the PSA test cannot be used to diagnose cancer. Further testing is always required before a patient can be diagnosed with cancer.

What should I do if my PSA is rising but still in the normal range?

If PSA is rising but still normal, talk to your physician about the best approach. The increase might be caused by age or activity levels. There is no reason to worry unless the PSA level rises outside of the normal range – and even then, it may not indicate cancer.