About Elevated PSA

PSA stands for prostate specific antigen. PSA is a protein in prostate cells.  It is made by benign and cancerous prostate cancer cells. So, while PSA is “specific” to the prostate, it is not “specific” to cancer. There are many tests that are used to help determine whether or not an elevated PSA is due to cancer. While an elevated PSA is an important finding, it is equally important to use good judgment in the workup of the elevated PSA.

• What causes an elevated PSA?

  There are many causes. These include prostate cancer, benign enlargement of the prostate, and inflammation or infection of the prostate. Recent sexual activity or a prostate exam can briefly raise the PSA.

• Does my elevated PSA mean I have prostate cancer?

  No. While a very high PSA suggests prostate cancer, a PSA above the traditional “normal range” does not mean that you have prostate cancer. The higher the PSA, the higher the chance that the PSA represents prostate cancer. It is also important to know that some prostate cancers do not produce much PSA and they have to be detected through other means such as a prostate exam or radiology study.

• With the limitations of the PSA test, should I even have it checked?

  Screening for prostate cancer is a controversial subject. While some people believe that since the PSA is not a perfect test to detect prostate cancer, it should not be performed at all. We at Minnesota Urology believe that constitutes “burying one’s head in the sand.” An elevated PSA is a clue and it should be addressed like any other clue: a piece of information that, when placed into the right context, can help you figure out a solution. Since more than 30,000 men will die from prostate cancer each year and only through early detection can we have much of an impact on that, we believe that a screening PSA is an important consideration for men with a life expectancy more than 10 years. Ideally, all men with a life expectancy of 10 years should have a thorough discussion with their doctor about both the benefits and risks of screening for prostate cancer.

• Are there tests that improve the accuracy of PSA?

  Yes. There are many ways of improving the accuracy of PSA testing. These include the change in PSA over time (or “PSA Velocity”), the presence of certain forms of PSA in the blood (“percent free PSA”), the ratio of the PSA to the size of the prostate (“PSA Density”), age specific PSA cutoffs and additional tests that may shed light on the risk of prostate cancer (PHI score, 4Kscore, ExoDx and others). These tests are non-invasive and require either blood or urine. They can be used to help determine the chances that an elevated PSA represents cancer. They cannot diagnose cancer.

• So how is prostate cancer diagnosed?

  The best way to diagnose prostate cancer is with a biopsy of the prostate. The most common way to do this is to insert a needle through the rectal wall and obtain tissue from the prostate. Typically, multiple biopsies or “cores” are obtained. The needle is guided by an ultrasound probe that is inserted into the rectum. The ultrasound image can identify areas that are suspicious for additional targeted biopsies. This procedure is usually performed in the office with local anesthesia. While most men do not require treatment for side effects, occasionally additional intervention is required for bleeding or infection.

• Can’t you do an X-ray and tell me if I have prostate cancer?

  Yes and no. Over the past few years, magnetic resonance imaging has been used to try to detect prostate cancer. It is rare that an MRI can definitively diagnose a benign or malignant prostate. Rather, a specialized radiologist reviews the images and grades the prostate from 1-5 using the PIRADS system. A score of 4 or 5 suggests that prostate cancer is likely to be present. There is also evidence that MRI is more likely to detect aggressive prostate cancer. A score of 4 or 5 still requires a biopsy to diagnose the cancer.

• Why should I have an MRI if the diagnosis will require a biopsy anyway?

  The MRI may show areas that are suspicious for cancer and that might not be targeted with a random biopsy.  Using special software and equipment called the UroNav Fusion Biopsy System, your urologist at Minnesota Urology can overlay the MRI images on a real-time ultrasound image and target the more suspicious areas, improving the accuracy over a standard biopsy.  Fusion biopsy systems have been shown to improve the accuracy of a prostate biopsy and detect more aggressive cancers.  Minnesota Urology adopted fusion biopsy as soon as it became available and our urologists have performed more than 3,000 fusion biopsies.

• Are there other ways of improving the accuracy of ultrasound-guided transrectal biopsy?

  Yes. Recently, a new, high-frequency ultrasound (ExactVu) was released, and preliminary data suggest that the improved image quality may enable more accurate biopsies than standard ultrasound biopsies. Minnesota Urology has adopted this technology and is actively working to determine how it will fit into the algorithm for the evaluation of an elevated PSA.