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Learn about the Wide Variation in Risk Calculator Results for a High PSA

A high PSA test level suggests a somewhat increased probability of prostate cancer.
However, for any high PSA level the risk calculators and 4Kscore produce very wide ranges of cancer risks.
For a high PSA of 6.0, we show below how cancer risk varies greatly based on possible results of informative screening actions. First for 4Kscore, then PCPT Risk Calculator, then ERSPC Risk Calculator.
The percentage values are the probability of high grade cancer for 4Kscore and the PCPT Risk Calculator and significant cancer for the ERSPC Risk Calculator. Significant cancer mainly reflects high grade cancer and includes large low grade cancer.

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4Kscore Percentage Risk of High Grade Cancer Estimates for High PSA

4Kscore acts like a risk calculator that considers a panel of four PSA related blood tests, age, DRE and previous biopsy. 

Percentage risk of high grade cancer based on 4Kscore values are shown below:

2.5% 4Kscore:

• 2.5%

5% 4Kscore:

• 5%

10% 4Kscore:

• 10%

20% 4Kscore:

• 20%

30% 4Kscore:

• 30%

40% 4Kscore:

• 40%

NOTE: If your 4Kscore is elevated, consider a follow-up 4Kscore for the same reasons to follow-up an elevated PSA.
PSA and 4Kscore can be increased by a temporary condition (infection or inflammation) that may moderate at follow-up.

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PCPT Risk Calculator Percentage Risk of High Grade Cancer Estimates for High PSA 6.0

Percentage risk of high grade cancer based on PCPT-RC variables are shown below for age 64 at elevated PSA 6.0 for Caucasian and other race men and for African American men:

NOTE: If your Free PSA % is low, consider a follow-up Free PSA for the same reasons to follow-up an elevated PSA.
Free PSA % can be decreased by a temporary condition (infection) that may moderate at follow-up.

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Caucasian, Hispanic and Other Race Men

Free PSA%

20% - 6%
15% - 9%
10% - 19%

DRE

None - 8%
Norm - 8%
Abnorm - 12%

Fam History

No - 8%
Yes - 9%

PSA

5 - 7%
6 - 8%
7 - 9%

Age

64 - 8%
66 - 9%
​68 - 9%

Prior Biopsy

None - 8%
​Neg - 7%
NotSure - 8%

Abnormal DRE &
​Free PSA%

15% - 13%
10% - 27%

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African American Men

Free PSA%

20% - 14%
15% - 22%
10% - 39%

DRE

None - 19%
Norm - 19%
Abnorm - 27%

Fam History

No - 19%
Yes - 22%

PSA

5 - 17%
6 - 19%
7 - 22%

Age

64 - 19%
66 - 21%
​68 - 22%

Prior Biopsy

None - 19%
​Neg - 18%
NotSure - 19%

Abnormal DRE &
Free PSA%

15% - 30%
10% - 49%

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ERSPC Risk Calculator Percentage Risk of Significant Cancer Estimates for High PSA 6.0

Percentage risk of significant cancer based on ERSPC-RC variables are shown below for elevated PSA 3.0 for various cases:

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PSA, No DRE, No Prostate Volume, No PHI, No Transrectal Ultrasound (TRUS)

No Previous Biopsy

5 PSA - 11%
6 PSA - 13%
7 PSA - 16%

Negative Previous Biopsy

5 PSA - 2%
6 PSA - 2%
7 PSA - 2%

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DRE with Prostate Volume, PSA 6, No Previous Biopsy, No PHI, No Transrectal Ultrasound (TRUS)

25cc Prostate Volume

Normal DRE - 17%
Abnorm DRE - 55%

40cc Prostate Volume

Normal DRE - 7%
Abnorm DRE - 30%

60cc Prostate Volume

Normal DRE - 3%
Abnorm DRE - 15%

No Prostate Volume

Normal DRE - 6%
Abnorm DRE - 30%

Vertical Divider

​CAUTION: Abnormal DRE causes a very much larger increase in cancer risk for ERSPC-RC than for PCPT-RC.
If abnormal DRE, consider TRUS ultrasound or MRI because a tumor large enough to be felt may be seen on images.

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PHI, Normal DRE with Prostate Volume, PSA 6, No Previous Biopsy, No Transrectal Ultrasound (TRUS)

25cc Prostate Volume

5 PHI - 8%
10 PHI - 13%
20 PHI - 21%
40 PHI - 32%
80 PHI - 44%

40cc Prostate Volume

5 PHI - 5%
10 PHI - 8%
20 PHI - 12%
40 PHI - 21%
80 PHI - 31%

60cc Prostate Volume

5 PHI - 3%
10 PHI - 5%
20 PHI - 9%
40 PHI - 14%
80 PHI - 22%

NOTE: If your PHI is elevated, consider a follow-up PHI for the same reasons to follow-up an elevated PSA.
PSA and PHI can be increased by a temporary condition (infection or inflammation) that may moderate at follow-up.

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Transrectal Ultrasound (TRUS) with Prostate Volume, Normal DRE, PSA 6, No Previous Biopsy, No PHI

25cc Prostate Volume

Normal TRUS - 11%
Abnorm TRUS - 29%

40cc Prostate Volume

Normal TRUS - 5%
Abnorm TRUS - 15%

60cc Prostate Volume

Normal TRUS - 2%
Abnorm TRUS - 8%

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PHI, Normal DRE with Prostate Volume, PSA 3, No Previous Biopsy, No Transrectal Ultrasound (TRUS)

For most men, the ERSPC Risk Calculator is critical for effective risk assessment and avoiding a premature biopsy. There are dramatic differences in risk for the same PSA level.

Using the ERSPC-RC, we focus on PHI and prostate volume for men with no other risk factors. For PSA 3.0, the graph on the right plots the probability significant prostate cancer will be found by biopsy as a function of PHI for three prostate volumes estimated by digital rectal exam (DRE): small (25cc), medium (40cc) and large (60cc).

Notice how steeply significant prostate cancer risk increases as PHI increases.

Click to enlarge.

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" elevated levels of PSA.

• At an elevated PSA of 3.0 and PHI of 20, the estimated probability of significant prostate cancer is:
  • 18% for a small 25cc DRE prostate volume
  • 11% for a medium 40cc DRE prostate volume
  • 7% for a large 60cc DRE prostate volume

The dramatic difference in risk for small and large prostates demonstrates why it is so important to consider prostate volume for elevated PSA levels. The risk level of 10% is the same at 8 PHI for a small prostate as at 31 PHI for a large prostate. Full interpretation of PHI depends on prostate volume.

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.