Archive - PSA

Tamsulosin is a drug frequently prescribed for men who have severe urinary symptoms from benign enlargement of their prostate. It does not shrink the prostate and does not lower the PSA level. Two other drugs that also are prescribed for treating benign enlargement are Avodart and Proscar. These drugs usually do shrink the prostate and lower the PSA level. Two concerns that I have about using these drugs are: 1) they may mask prostate cancer and create a false sense of security about the PSA level being lower than it really is, and 2) patients taking these drugs for several years have a significantly higher incidence of being diagnosed with the highest Gleason grades (most aggressive) of prostate cancer (Gleason grades 8, 9, or 10).

The median PSA level for a man in his 60s is 1.3 and for a man in his 70s is 1.7. Men whose PSA is higher than the median for their age group are at an increased risk for having prostate cancer. Thus, your PSA of 6.3 is concerning. The cause for the high PSA could be prostate cancer, benign enlargement of the prostate, inflammation in the prostate, or any combination of these conditions. The fact that the PSA decreased suggests that inflammation is at least part of the cause. Nevertheless, you should be evaluated by a urologist. I am now using the Prostate Health Index (phi) blood test for this purpose, as it provides more information than the standard total PSA and free PSA tests. See the Spring 2014 Quest for more information on the phi test.

Two important missing pieces of information are whether you are healthy and the Gleason grade of your tumor. I would advise you to have the slides reviewed by another pathologist. If the diagnosis of prostate cancer is confirmed and you are healthy, because of your young age, in my opinion a nerve-sparing prostatectomy would be preferred over surveillance or radiation therapy. Prostate cancers arising in men with low testosterone sometimes are more aggressive.

No. The dramatic increase in his PSA may not be due to prostate cancer and could be due to inflammation in his prostate. If it is, the PSA might spontaneously decrease with or without antibiotic treatment. In any case, he should be evaluated for a possible urinary tract infection and prostatitis. Currently, the best imaging test for prostate cancer is called a “multi- parametric MRI scan,” but this scan is not as certain as a biopsy. An important factor in deciding whether to pursue the diagnosis or treatment of prostate cancer is the patient’s life expectancy from other illnesses. He should discuss this issue with the oncologist who is treating his lymphoma.

The fact that the PSA is as high as 5 to 7 indicates that the laser treatment has not ablated the entire prostate gland. Whether this PSA is being produced by benign prostate tissue or cancer is uncertain, although when the cause is cancer, the PSA usually rises progressively. A special type of MRI scan that uses a powerful (3 Tesla) magnet can be useful in identifying regions of cancer within the prostate – particularly high-grade cancer. However, imaging is not as accurate as biopsy. Frequently, a MRI scan is obtained and then followed by a targeted biopsy of any suspicious region.

The value of percent free PSA is to help decide whether a prostate biopsy is indicated. If the total PSA is higher than 10, the risk of finding prostate cancer on a biopsy is greater than 50% and a biopsy is usually indicated. That is not to say that the percent free PSA is meaningless. If it is approximately 10% or lower, the risk of cancer increases.

It is always reassuring when an elevated PSA level returns to normal with or without antibiotic therapy. In my opinion, all men who are concerned about the possibility of having prostate cancer should monitor their PSA levels annually. This is a subject to debate, as some physicians do not believe in any routine PSA testing, but I think this is ill advised for most men. Nevertheless, the PSA test is a simple blood test that could save your life.

In the general population, the median PSA is approximately 0.7 for men in their 40s, 0.9 in their 50s, 1.3 in their 60s, and 1.7 in their 70s. This means that half of the population has levels below the median and half have them above the median. If the PSA is above the median, the risk of being diagnosed with prostate cancer is higher than in the general population. This being said, there are conditions other than prostate cancer that can cause the PSA level to be elevated, such as benign prostatic enlargement or inflammation in the prostate. Now, a new blood test called the Prostate Health Index (PHI) is available. It is several-fold more accurate than the total and free PSA tests that have been used in the past. This test has been approved by the FDA for men whose PSA is between 4 and 10. I recommend that you see a urologist to help determine why your PSA level is 7.5.

Some doctors would say the PSA level is normal if it’s below 4 ng/ml and above normal if it’s above 4 ng/ml. I believe that the cutoff of 4 is too high and we have used 2.5 as our cut off in our PSA screening study since 1995. We have proven that if the PSA is between 2.5 and 4, there is a 22 percent chance that the man will have prostate cancer. We routinely recommend a biopsy if the PSA is above 2.5 and if the free PSA test confirms the advisability of performing a biopsy. Even men with PSA levels lower than 2.5 might have prostate cancer. In our studies, the median PSA level in men without known prostate cancer was less than 1 in men in their 40s and 50s and less than 1.5 in men over the age of 60. It the PSA level is higher than the median for the age group, the risk of prostate cancer is higher. So, if the PSA level is above the median and especially if it is rising, a biopsy should be considered.

Prostate cancers when looked at under the microscope can look like almost normal prostate tissue or they can look very wild and disorganized. They are graded on a scale called the Gleason grade of between 2 and 10 where 2 is the best, i.e., a low grade, slow growing prostate cancer, and a 10 would be the worst, i.e., a rapidly progressing, very aggressive prostate cancer. It turns out that grade level statistics for prostate cancer fall into a bell shaped curve. Only about 10 percent of tumors are grade 2, 3 and 4 and only about 10 percent of tumors are 8, 9 and 10 with the vast majority being Gleason grades 5, 6 and 7. Gleason grades 8-10 are considered highly aggressive, Gleason 7 is considered moderately highly aggressive (4+3 is considered to be more aggressive than 3+4), Gleason 3+3 is considered mildly aggressive, and Gleason 2-4 is considered so non-aggressive that immediate treatment might not be needed in men over the age of 70.

It can if it results in sexual intercourse with ejaculation. Ejaculation elevates the PSA level for 24 to 48 hours.

A: Not directly. Personal stress can cause sexual dysfunction or lower the body’s resistance to infection. That lowering might lead to prostatitis, and prostatitis can raise the PSA level temporarily.

Sexual activity can cause a transient rise in the PSA level. This is usually a minimal rise and does not last for more than a 6 to 24 hours. Sex with or without a penile implant does not make a difference. It is ejaculation that causes the PSA to rise. It is ideal to avoid sex for 24 hours before PSA testing.

If you ran the test on the same sample three times, the error should be no more that 3% or so. If you drew a blood sample on three successive days the variation may be as great as 10-15%.

Our studies show that prostatic biopsies can easily miss prostate cancers. In our recent analysis of more than 2500 men who underwent one or more prostate biopsies, of those who had cancer detected, only 77% had the cancer discovered on the first biopsy. Of the rest, 91% were discovered on the first or second biopsy, 97% on the first three biopsies, and 99% on the first 4 biopsies. Some men required 6 biopsy sessions to detect the cancer. So, with each biopsy session there is increased confidence that the high PSA might not be due to cancer. However, there is a current trend among urologists to obtain more biopsy cores during each biopsy session and to perform the biopsies under local or general anesthesia so that more biopsy samples can be obtained without undue discomfort. It is also important to ensure that the biopsies are directed to the zones of the prostate where most of the cancers are found. In some men the cancer may be located in the central region of the prostate gland where biopsies are not usually directed. Sometimes these cancers can be best detected on transurethral recection biopsies, obtained under anesthesia through a scope that is passed into the central part of the prostate gland. These biopsies are sometimes called “saturation biopsies.” Some men with high PSA values do not have prostate cancer. Other options are to try a long course of antibiotics such as Cipro 500 mg twice a day to see if it brings the PSA down. Other criteria to consider is the PSA density (PSA divided by prostate volume). If it is higher than 0.10, it is worrisome for prostate cancer. Also, measuring the percentage of free PSA (free PSA/total PSA x 100). If it is lower than 25%, it is of concern – and the lower, the more concerning. Certainly, annual biopsies are not unreasonable, especially if the PSA or other parameters continue to suggest a higher risk for prostate cancer.

The PSA increase may be due to inflammation in the prostate. So, the first step is to take a 10 to 14 day course of antibiotics (such as Cipro 500 mg twice a day). Of course, if the PSA does not come back down, a biopsy of the prostate should be considered.

When the total PSA is between 4 and 10 and the percentage of free PSA is less than 10, there is about a 58% chance that biopsies will show cancer. This means that there is a 42% chance that the biopsies will not show cancer. I would advise that you monitor the total PSA level and the free PSA level, and if the total PSA level rises, consider further biopsies. It is possible that with a large prostate gland, there could be areas of cancer that were missed by the first two sets of biopsies. If you want to be as pro-active as possible, you might want to consider repeating the biopsies again in one year. It is well established that BCG therapy for bladder cancer can induce chronic inflammation in the prostate gland that can result in a long-term elevation of the PSA level.

There is still much to be learned about free PSA. We now know that there are several forms of it. One form is low in cancer and high with benign enlargement of the prostate. However, another form is high in cancer. In general, a low percentage of free PSA is worrisome for cancer – but not always. There are some men who have a low free PSA and do not have cancer. We don’t know all of the explanations at this time.

There are several possible explanations. Part of the high PSA could be due to benign prostatic enlargement or inflammation in the prostate. The cancer may be contributing a relatively small proportion of the PSA. Another possibility is that the biopsies may have failed to detect other regions of cancer within the prostate due to simple spatial sampling errors.

Yes. A PSA count of 10 is high at any age. It indicates that there is either benign enlargement of the prostate, inflammation in the prostate, prostate cancer – or a combination of the above. It would be prudent to be evaluated by a urologist.

The answer to all three quesitions is yes. Usually, ejaculation or a prostate exam has only a slight effect on the PSA level that lasts for 24 to48 hours only. The PSA might increase a point or two. With infection, very high PSA levels can occur (even up to 21 or higher) and in some cases it takes a long time for the PSA levels to return to baseline. In about 25% of cases, antibiotic therapy is effective; however, some men have to wait for their body’s defense mechanisms to clear the infection.

A rising PSA in a patient on Proscar is worrisome for prostate cancer. There are treatments to slow the progression of the cancer. The size limits some treatments, but not radiation or stronger hormonal therapy. If the PSA increase is due only to prostate cancer, it indicates a rapidly growing tumor; however, the increase could also be due, at least in part, to inflammation in the prostate (see other Q&A s on this topic). It never hurts to get another opinion from another urologist, medical oncologist or radiation oncologist.

The only medicines that affect PSA levels are hormones. Medicines that lower male hormones can decrease PSA levels. The only way a cough or cold medication could affect the PSA level would be if it caused urinary retention. Urinary retention can result in a dramatic increase in the PSA levels.

I do not believe so. There are probably other causes (benign enlargement of the prostate, inflammation in the prostate, prostate cancer, or combinations of the above). See other questions on the website. Ejaculation usually causes only low-level transient elevations of the PSA level.

Pro-PSA is a “new” marker. Preliminary studies indicate that it may be a better marker than free or complexed PSA, but a Pro-PSA test is not available at this time. The test and its results are still in the research stage. Some papers are published on clinical studies using Pro-PSA, and they can be found on the internet in PubMed, a service of the National Library of Medicine, www.pubmed.com. The Fall 2003 issue of Quest had an article on Pro-PSA, “Pro-PSA: Possibly a Better Marker for Prostate Cancer.”

It is possible that a 12-core biopsy could have missed a prostate cancer, so you cannot be 100% certain that there is no prostate cancer. You should continue to be followed with PSA testing and digital rectal examination and consider repeating the biopsy if either test becomes more abnormal. There might be as high as a 15% to 20% chance that you could be diagnosed with prostate cancer in the relatively near future, in my opinion.

Yes. In recent years, it is very uncommon for pathologists to score prostate cancer in the low end of the Gleason scoring range (less than Gleason sums of 5). It is always a good idea to have slides reviewed, and especially so in this case.

In my opinion, he almost certainly has advanced prostate cancer. If it does cause symptoms, it is very likely that he could be successfully treated with hormonal therapy. If he does not wish to have a biopsy, he should be monitored closely by an experienced urologist who would be prepared to intervene appropriately.

In my opinion, nothing but to continue to watch the PSA carefully and to be willing to have more biopsies if the PSA rises further. Biopsies in the anterior and the central regions of the prostate are especially important in cases such as yours.

The adrenal glands normally produce male hormones in relatively small quantities that can affect PSA levels. In fact, some treatments for advanced prostate cancer, such as keotconazole probably lower PSA levels by eliminating the production of male hormones by the adrenal glands.

I is more likely to be prostatitis because of your young age, but it could be cancer – especially if you have a family history of early age at onset prostate cancer. If the PSA does not decrease below 2.5 with the antibiotics, I would recommend that you have a biopsy.

Many men have a high PSA because of benign enlargement and/or inflammation and do not have cancer. The odds are that you are one of these men. It is important to stay under the care of a urologist and make sure you go in for scheduled tests and check-ups. These may include repeated biopsy sessions, especially if the PSA continues to rise, as biopsies are only small samples of the prostate gland, and it is not infrequent that initial biopsies miss the cancer.

It could if your testosterone level was low to start with (as it presumably was) and therefore was masking your true PSA level. If the PSA is high, you should consider a prostate biopsy

In my opinion, a PSA of 2.9 is too high. I would continue to monitor the PSA quarterly, and, if it does not continue to decrease, would recommend a biopsy.

At age 37, the most likely cause of your PSA elevation is prostatitis. It is further supported by the fact that your PSA level came down. However, at age 37, a PSA of 2.9 is high, and I would monitor the PSA more frequently – say every three months for a while. If it does not go down to below 1, I would suggest that you consider a biopsy.

No.

Not to my knowledge. Neither gout or the medications used to treat it affect PSA levels. The most common cause of a fluctuating PSA level is inflammation in the prostate gland, but it is possible also to have benign enlargement and cancer. I would advise another course of antibiotics, and if the PSA does not return to baseline, I would advise a prostate biopsy.

Inflammation in the prostate, also called prostatitis. However, remember that a PSA of 4.8 and 5.4 is high and it is possible to have both prostatitis and prostate cancer. If the PSA does not decrease to below 2.5, I would recommend that you have a prostate biopsy. Please see other Q&As on my website referring to fluctuating PSA levels.

I would recommend asking your urologist to culture your urine and try a 4 to 6 week course of antibiotics, such as Cipro 500 mg twice a day, to see if that has a beneficial effect on your symptoms and PSA level. Your urologist might want to check your urine for abnormal cells with a cytology test and might want to perform cystoscopy to ensure that everything looks alright on the inside. It might be necessary to repeat the biopsy procedure in the future.

A high PSA does not always mean cancer. It can be caused by an enlarged prostate gland, inflammation in the prostate gland, or other benign conditions. However, the higher the PSA, the greater the likelihood that prostate cancer is present.

It can raise PSA levels if the PSA levels were suppressed because of the low testosterone level, which often is the case when the testosterone level is low enough to warrant treatment. However, if the testosterone levels are not abnormally low, giving additional testosterone might not increase the PSA levels.

Pro-PSA is not yet available for clinical use. No guidelines have been established at this time.

You could start at once and get a baseline PSA and digital rectal examination, and, in my opinion, it would not hurt to repeat it annually. In any case, I would not recommend waiting until after age 40.

At least annually, and, in my opinion, every 6 months would not be too often. A 45 year old’s PSA should be less than 1.0 ng/ml at age 45. If it is higher, I would advise a course of antibiotics and if the PSA did not decrease to lower than 1, I would advise considering a biopsy.

The median PSA value for men in their 40s is about 0.6 ng/ml. If the PSA is higher, there is a higher risk of being diagnosed with prostate cancer. I would advise you to try a course of antibiotics and if the PSA did not decrease to lower than 1, I would advise you to consider having a biopsy. If you do not have a biopsy, you should follow your PSA very closely.

Your PSA is a little bit higher than that of the usual 52 year-old man (median PSA 0.6-0.9). With your family history, I would advise you to continue to follow it carefully and if it trends upward at all, I would recommend that you consider having a biopsy.

In my opinion, yes. I would advise you to have a biopsy.

It could. We now know that “free” PSA is made up of several components: BPSA and IPSA that are increased with benign prostatic enlargement (BPH) and proPSA that is increased with cancer. So, if the prostate shrinks because of treatment of BPH, the free PSA level could decrease.

It is hard to say, but certainly higher, and high enough to recommend a biopsy.

Although your tumor features and PSA velocity are favorable, I would not recommend watchful waiting because of your young age. Your prostate cancer will have a long time to progress, if you are otherwise healthy, and the earlier you have it treated, the better, in my opinion.

The range is from 0 to thousands. In men with a perfectly healthy prostate gland (i.e., no benign enlargement, no inflammation, no cancer) the PSA should be less than 1. Any of these conditions can raise the PSA level. However, there is a direct association between the PSA level and the risk of cancer. It is about 10% to 15% if the PSA is less than 2.5; about 25% if the PSA is 2.6 to 4; about 35% to 40% if the PSA is 4-10; and more than 50% if the PSA is higher than 10. See the Quest article of August 2004 for more recent information on other PSA measures such as PSA velocity, PSA density, Pprcent free or complexed PSA, etc.

They have no effect on the PSA level. Only urinary tract and prostate infections affect the PSA.

If the suspicious cells were high-grade PIN (prostatic intraepithelia neoplasia) or ASAP (atypical small acinar proliferation), and the percent free PSA is decreasing to 6%, I would be concerned. However, it is reassuring that his total PSA has not increased for the past two years. Perhaps, the safest course would be to repeat the biopsy procedure. If you do not wish to do this, I would recommend that the PSA levels be measured every 3 to 6 months.

No. In fact, emerging evidence suggests that medications for cholesterol (statins) might lower the risk for prostate cancer and might decrease the aggressiveness of prostate cancer.

No, there isn’t.

Men with a family history of prostate cancer are often biopsied at a younger age– due to an elevated PSA – than men without a family history of prostate cancer.

Men with a family history of prostate cancer are diagnosed with prostate cancer at a younger age than men without a family history of prostate cancer.

A family history of prostate cancer appears to be associated with a higher rate of cancer diagnosis among men with a total PSA level from 2.5 to 4.0 ng/ml or a PSA Velocity of more than 0.75 mg/ml in a year.

Although family history of prostate cancer is associated with an increased risk of cancer diagnosis, it is not associated with more aggressive tumor features.

(taken from a URF sponsored study presented at the May, 2008 AUA meeting)

There is truth to the fact that not everyone with a high PSA value has prostate cancer, especially if the PSA decreases spontaneously or in response to antibiotic treatment.

However, the median PSA value for men in their 50s is less than 1 (0.9), and the higher the PSA is above that value, the more likely they have prostate cancer.

If your PSA does not decrease dramatically, I would recommend a biopsy.

Although a very high PSA level in this range can sometimes be seen in men with benign enlargement of the prostate and/or prostatitis, there is a very high likelihood that it indicates the presence of prostate cancer, especially if it remains elevated after taking a 2-week course of antibiotics, or on repeated measurements over time.

Only if there is prostate tissue remaining in your body or if the cancer has spread prior to the removal. If all prostate tissue has been removed and it has not spread prior to removal, testosterone should not affect the PSA level, which should be 0.

This rapid increase is most likely too fast to have occurred because of cancer. Other possible causes would be inflammation in the prostate or manipulation of the prostate such as a DRE (digital rectal exam), or even recent ejaculation. It could be evaluated by repeating the PSA after an interval of 4 weeks or after a 2-week course of antibiotics.

In general I recommend a biopsy in men who have a PSA greater than 2.5 if they are otherwise healthy and have a life expectancy of 10 years or more.

If the PSA is due to prostate cancer, the level almost always continues to rise unless there has been some treatment of the cancer.

The median PSA level for men in their 50s is 0.9; therefore, levels of either 2.9 or 5.6 are quite high. The three most common causes of an elevated PSA are inflammation in the prostate, benign enlargement, and prostate cancer. Few men in their 50s have enough benign enlargement to raise their PSA level to 5.6, and the magnitude of this increase in 18 months is too great to be caused by benign enlargement (and almost too great to be produced by most prostate cancers). Inflammation is most likely the cause in your case. In my practice, I use the Prostate Health Index blood test to help discriminate between PSA elevations caused by benign conditions versus cancer, but this test is not perfect. No MRI scan can be considered a substitute for a biopsy. The state-of-the-art scans use a 3 Tesla magnet. If the MRI scan suggests that cancer is present, cancer is found on biopsy about 50% of the time. If the MRI scan detects no regions that are suspicious for cancer, there is still about a 15% chance that a significant prostate cancer is present.

Depending on the context, such as prostate size, previous PSA results, history of prostatitis, or prior biopsies, your initial PSA of 4.3 usually would be considered concerning. The increase to 5.1 and the percent free PSA being less than 10% is more concerning (would like to see it above 20%). The testosterone treatment would be unlikely to be harmful, unless your testosterone levels were low to begin with, in which case adding more testosterone could stimulate the growth of prostate cancer. Thus, based on the information you provided, there seems to be a clear indication for performing the biopsy.

Usually, this indicates that the elevated PSA was due to inflammation in the prostate, so a biopsy might not be required. However, if the patient is very young, a PSA of 1.6 could still be high. Also, if the findings on digital rectal examination or MRI are concerning for cancer, a biopsy still may be considered.

Presumably, the testosterone replacement therapy is merely restoring your testosterone to normal levels. Therefore, your 0.5 ng/ml increase in PSA during the past year has the same meaning as it would in men not taking testosterone replacement therapy. PSA increases caused by benign enlargement of the prostate are usually in the range of 0.15 ng/ml/year. With prostate cancer, they are usually more than 0.35 ng/ml/year. Large increases in PSA frequently occur in men with inflammation in the prostate, but PSA levels subsequently decrease as the immune system controls the prostate inflammation. Therefore, I would recommend repeating the PSA. If it rises persistently, I would recommend a prostate biopsy. If you stop the testosterone pellet implantations, your testosterone levels would drop dramatically and there would be a corresponding decrease in the PSA levels, but this would be like any patient with normal testosterone levels initiating androgen deprivation therapy.

The short answer is “yes.” The bottom line is that it becomes very difficult to accurately detect PSA at levels less than 0.10 ng/mL. However, it might mean that if PSA is not detected, PSA could still be there in concentrations less than the limit. For example, <0.008 ng/mL means there might be PSA present less than 0.008, but the lab is unable to detect lower than the limit of 0.008. This explains why different patients receive different levels of undetectable results.

The fact that the total PSA remained the same makes the change in the % free PSA less concerning. Such fluctuations are fairly common. Continuing monitoring should clarify the situation. In my practice, I would use a new blood test (prostate health index) that measures several different forms of PSA to assess prostate cancer risk.

This is probably best explained by an episode of prostatitis. The prostate is located right next to the rectum, and it is possible for intestinal bacterial to enter the prostate through lymphatic channels causing infection, inflammation, and swelling of the prostate. This causes the PSA to rise. As the body’s immune system takes care of the inflammation, the PSA levels decrease. Nevertheless, 3.9 is still high, so you should continue to monitor it to see if it returns to the previous levels. Labetalol can cause retrograde ejaculation and thus appear to decrease semen production, but it does not affect PSA levels.

Not if your prostate was completely removed.