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High PSA? What Next? | Prostate Smart Screening Strategy Analysis
HIgh PSA test level? (greater than 5.0) | Before prostate cancer biopsy: analyze your PSA trend, use new screening technology and consider smart screening strategy analysis.
PSA is the prostate-specific antigen blood test measured in ng/mL that reflects prostate conditions.
If your PSA less than 5.0, then see our Elevated PSA? What Next? | Smart Screening Analysis page.
If your PSA is low but increasing, then see our Increasing PSA? | What Next? page in a new window.
Learn more about Prostate Smart Screening for Cancer at our home page in a new window.
Take Next Steps to Develop Your Smart Screening Strategy
- Understand your "Underlying" "True" high PSA.
- Learn about the many possible causes of your high PSA.
- Interpret your high PSA and prostate volume.
- Analyze your high PSA trend.
- Develop your Prostate Smart screening strategy for your high PSA.
1. Understand Your "Underlying" "True" High PSA
A high PSA (greater than 5.0) or an elevated PSA (less than 5.0) provide early warning of prostate activity for a smart prostate cancer screening strategy. (Links take you to one of our website pages that opens in a new window.)
Your "Underlying" "True" high PSA is the value that your physicians should use to assess your risk with the help of prostate cancer risk calculators or rules of thumb about threshold level of concern, such as 4.0 or 3.0 or an age-adjusted threshold level. Learn about risk calculators in the Blog post: Use prostate cancer risk calculators to avoid premature biopsy that opens in a new window.
Your "True" high PSA is Hybritech calibrated and adjusted for specific medications to treat prostate enlargement (BPH). See the Blog post: Elevated PSA? Is your "True" PSA higher? that opens in a new window.
Your "Underlying" "True" high PSA test level may be lower than your most recent "True" high PSA value because of temporary infection, inflammation or aggravation of your prostate. See the Blog post: Elevated PSA? Is your "Underlying" PSA lower? that opens in a new window.
2. Learn about the Many Possible Causes of Your High PSA
A high PSA suggests activity in the prostate that usually is not cancer. Some of the causes of high PSA are related to aging:
Follow-Up PSA after High PSA
The many temporary causes of high PSA test levels help make a strong case for a follow-up PSA testing 4 to 6 weeks later when PSA may decrease.
3. Interpret Your High PSA and Prostate Volume
The probability of prostate cancer:
- Increases as PSA increases to high levels.
- Increases as prostate volume decreases to small sizes..
What Is the Probability of High Grade or Significant Cancer for High PSA Levels?
The highly regarded ERSPC Risk Calculator estimates the probability of significant prostate cancer (mostly high-grade and some large low-grade) and the probability of any prostate cancer.
Here, we focus on two of the most important factors, PSA level and prostate volume, for men with no other risk factors. The graph on the right plots the probability significant prostate cancer will be found by biopsy as a function of high PSA levels for three prostate volumes estimated by digital rectal exam (DRE): small (25cc), medium (40cc) and large (60cc).
Notice for each prostate volume curve that the probability of significant prostate cancer increases as PSA increases to high levels.
Notice that the probabilities are much higher for a small prostate (the top red curve) than for a large prostate (the bottom blue curve). The probability of cancer is lower for large prostates because they tend to produce more PSA that "explains" high levels of PSA.
The dramatic difference in risk for small and large prostates demonstrates why it is so important to consider prostate volume for high PSA levels. The risk level of 6% is the same at a very high 10.0 PSA for a large prostate as at an elevated 3.0 PSA for a small prostate.
Ask your physician to estimate your prostate volume by digital rectal exam (DRE). Ask for a transrectal ultrasound (TRUS) to measure your prostate volume more accurately before considering a biopsy. To learn more, see our Ultrasound-Based Prostate Cancer Smart Screening Analysis page in a new window.
Why Does the Probability of Prostate Cancer Increase as PSA Increases to High Levels?
There are many non-cancer causes of high PSA including prostate enlargement, as described in Section 2 above.
However, in the absence of prostate cancer the number of men with a given PSA level decreases steeply as PSA increases to high levels. For example, many men without prostate cancer have a PSA of 1.0, few men have an elevated PSA of 5.0 and very few men have a very high PSA of 10.0.
In contrast, for men with prostate cancer the number of men with a given PSA level decreases more gradually as PSA increases to high levels, partly because larger tumors produce higher levels of PSA.
Therefore, the ratio of men with prostate cancer to men without prostate cancer increases as PSA increases, which translates into an increasing probability of prostate cancer as PSA increases to high levels.
4. Analyze Your High PSA Trend
PSA trend analysis is a rigorous way of analyzing periodic (or annual) PSA tests to extract the most information.
For example, very fast growing prostate cancers that produce fast growing PSA are relatively rare but very dangerous.
In contrast, slow growing cancers that produce slow growing PSA may pose little or no threat with biopsy delay the best strategy.
Prostatitis caused by infection and/or inflammation and prostate enlargement caused by benign prostatic hyperplasia (BPH) can cause PSA to vary up and down around an increasing PSA trend with biopsy delay the best strategy.
For example, some men experience periodic infections of the prostate or urinary tract that cause their PSA to increase temporarily. It would be a big mistake to use a temporarily increased PSA to assess underlying prostate cancer risk or estimate growth rate in PSA from cancer.
The graph shows 10 annual PSA tests that vary up and down with a slow underlying increase. The PSA peaks reflect temporary infection and/or inflammation. The lower PSA tests may reflect underlying conditions, such as prostate enlargement (BPH) or cancer.
PSA Pattern for Periodic Infections
Learn about PSA and Free PSA Trend Analysis in a new window.
5. Develop Your Prostate Smart Screening Strategy for Your High PSA
For men who want to lead a collaborative team effort rather than be a passive patient.
Prostate Smart analysis helps you create your strategy with your collaborative team of physicians and confidants to minimize your risks of:
> Regrettably late diagnosis of deadly cancer:
> Premature biopsy, diagnosis, treatment and side effects:
Analysis is needed to create the best personal screening strategy for you because:
We analyze published studies and present the implications for personal decisions. Studies are from: Mayo Clinic, Cleveland Clinic, Johns Hopkins, Memorial Sloan Kettering, NIH, NYU, UCLA, UC London, Yale and more.
Learn more about PSA-Based Prostate Smart Screening Strategy Analysis in a new window.
Return to Prostate Smart Screening for Cancer home page.