Raised PSA levels – when should you be concerned?

Receiving a high PSA test result can be a huge worry for men and their loved ones. However, it’s important to remember that a raised serum PSA level doesn’t always indicate a cancer diagnosis. While it might suggest that something is amiss, PSA levels can rise and fall for a number of reasons, so it’s important to look at the context – and consult an expert…

What is PSA?

A PSA test is a routine, simple blood test, used commonly in the UK for men considered to be at risk of prostate cancer. PSA, or ‘prostate specific antigen’, is an enzyme produced by the prostate gland. It can be identified in small amounts in the blood and is usually reported in units of ng/mL. 

PSA levels – what is ‘normal’?

While it is true that higher PSA levels are associated with prostate cancer, there are many reasons why an individual’s serum PSA level might rise. Without the full context and medical history, an isolated report of raised serum PSA levels can’t be taken as a reliable indicator of prostate cancer.

The transmission of PSA into the blood is usually limited by the impermeability of the lining of the glands and blood vessels in the prostate, which is why ‘normal’ PSA levels tend to be lower. However, the impermeability of the blood vessels can be interrupted by any number of causes, from infection through to ‘trauma’ caused by ejaculation or vigorous cycling, all leading to higher PSA levels in the blood.

Context is everything

For a raised PSA level to be considered of concern, one of the first things your doctor will want to do is to rule out a urinary infection. This can be done with a simple microbiological urine test. It’s important to treat any infection found, and then wait for a few weeks to allow the raised PSA levels to return to normal. 

Repeat testing is also important. One-off high serum PSA results are less worrying than a level that remains high on several occasions. Most men will be advised to avoid any trauma to the area (no cycling or ejaculation) for a few days before testing. 

Age-related differences

A raised PSA level doesn’t mean the same thing for every individual. Traditionally, age-specific PSA cut offs have been used for men of different ages. For example, a 49-year-old man with a PSA level of 2.7 might be referred for urgent investigation, while the same levels may not be considered significant in a 75-year-old.

However, this approach too could be oversimplified as it doesn’t account for differences in life expectancy, health issues, fitness levels, family history, ethnicity and so on. Nor does it account for variations in prostate size.

Prostate size

Because benign prostatic enlargement is very common as men age, and benign prostate tissue produces PSA, serum PSA levels always need to be considered in the context of prostate size. This can be estimated with a physical examination, but an ultrasound or MRI is recommended for precise measurement. 

PSA density

Another indicator of prostate cancer is a higher PSA density level. Here, the serum PSA level is divided by the volume of the prostate to calculate the PSA density. PSA density levels over 0.12 are of concern. 

If, in the absence of infection or recent trauma, a higher PSA density level is found, the patient would normally be referred for a multi-parametric MRI scan, not only for an accurate measurement of the prostate volume, but to highlight any suspicious areas to be targeted at biopsy. 

Why consult a urologist

It’s important to remember that PSA levels cannot be interpreted in the same way for all men, except at the lowest levels (<1ng/mL at 60 years old) which would normally indicate extremely low risk of significant prostate cancer. The job of the urologist is to interpret the serum PSA result in its fullest context, using MRI where appropriate, to calculate the risk to each individual patient.

Because prostate cancer is usually slow growing and can usually be controlled with medication, even after it has spread, the risk of a patient dying from any cancer identified will depend on the patient’s age and the presence of other significant medical conditions.

Next steps

Understanding your PSA results is a complex task, and your full medical profile, age and other factors will all be taken into consideration. 

If you are concerned about your PSA level, are at higher risk of prostate cancer due to a family history of breast or prostate cancer, or are of African or Caribbean heritage, you should see a consultant urologist who understands the use of PSA measurement and the way prostate cancer behaves, to help you make a considered decision as to whether further investigation is warranted.

At The Prostate Centre, part of HCA UK, we specialise in the diagnosis and treatment of prostate cancer. If you have any concerns you would like to discuss, simply book an appointment to see one of our specialists.