Raised PSA

What should I do if I have a raised PSA?

If you have a raised PSA or you have been told that your prostate feels abnormal, you should contact your GP or your urologist for further advice.

PSA (prostate-specific antigen) is a small protein molecule which is released from the prostate gland into the bloodstream. As you get older, your prostate slowly enlarges and your PSA gradually increases. The larger your prostate, the higher the PSA.

Prostate cancer (pictured) also becomes commoner with increasing age. By the age of 90 years, almost all men will have microscopic areas of tumour in the prostate. This does not mean that they have active prostate cancer. Many elderly men live a normal lifespan without the need to treat these “incidental” tumours.

Only detailed urological investigation can determine whether a prostate cancer is “incidental” (requiring no treatment) or “significant” (requiring active treatment).

What are the facts about a raised PSA?

  • PSA is not a specific test for prostate cancer. Raised levels may also be caused by inflammation, benign enlargement or previous surgery.
  • With PSA levels between 3 and 10, only 20% of men have prostate cancer on biopsy.
  • Higher levels of PSA make prostate cancer more likely (50% chance with a PSA greater than 10) If your PSA is raised, you will probably have a further blood test to measure the free/total PSA ratio (FTR). An FTR of less than 17% makes prostate cancer more likely. Levels greater than 22% usually mean that the prostate is benign.
  • If there is a high suspicion of prostate cancer on the basis of the blood tests, you will normally be advised to have biopsy samples taken from your prostate gland.
  • Even negative biopsies do not always rule out prostate cancer. Further biopsies may be needed if your PSA remains raised or increases with time.
  • If prostate cancer is present, the best way of treating early prostate cancer is still not known with any certainty.

What should I expect when I seek further advice?

1. History, examination & additional tests

Your GP will normally assess your general health, examine your prostate (by rectal examination, pictured) and ask about any prostate symptoms you may have. A further blood test, to measure the free/total PSA ratio, may also be arranged. You will normally have tests of kidney function, bone function, liver function and your GP may check your blood cells for anaemia or other abnormalities. Newer tests for prostate cancer, which are thought to be more specific (e.g. the PCA3 urine test), are not available to GPs and are only performed by a few urologists because they are still under assessment.

2. Risk calculation

Click here to see the prostate risk indicator for prostate cancer. This opens in a new browser window and takes account of a number of factors to produce an approximate risk of prostate cancer.

This should not be used as a substitute for a full discussion of risks with your urologist.

3. Initial treatment from your GP

If your PSA is greater than 100, your GP may start you immediately on hormone treatment (before you are seen in the urology clinic). This PSA level means it is likely that prostate cancer is present and that it is no longer confined to the prostate gland. Your GP may also arrange a bone scintigram (bone scan) if he/she is able to do this.

What happens next?

If your PSA remains raised, if the free/total ratio is low or if your GP suspects that your prostate feels abnormal, a referral will be arranged for you to see a urologist using the fast-track (2-week wait) system.

In a urology clinic, you will be assessed carefully by a urologist or a urology nurse specialist. Based on this assessment, it is likely that you will be advised to have transrectal ultra-sound guided biopsies of your prostate. This procedure may be performed at the first visit or at a later stage, and you should read the information leaflet before the procedure is performed.

Click here to see a calculation of the risk of biopsy-detectable prostate cancer

It may take up to a week before you get the final results of your prostate biopsies. The biopsies are analysed under a microscope (pictured right) to determine whether prostate cancer is present. If it is, the tissue is examined in more detail to determine the grade of cancer (the Gleason grade). This is done by looking at the characteristics of individual groups of cancerous cells. Once the biopsies have been examined carefully, the results will be discussed in a multi-disciplinary meeting where a number of specialists will consider them in detail.

If your prostate biopsies are negative for prostate cancer

You will normally be advised about treatment of any prostate symptoms you may have and your urologist will arrange for you to have regular (6-monthly) blood tests to check your PSA. If the PSA level remains raised or increases with time, you may be advised to have repeat biopsies or to have biopsies performed under a general anaesthetic (saturation biopsies). The latter allows more extensive sampling and is more likely to detect prostate cancer if it is present. More accurate still is a technique where your ultrasound scan is superimposed on an MRI scan. This technique is probably more sensitive in detecting prostate cancer but is still under assessment.

If your prostate biopsies are positive for prostate cancer

Your urologist will then discuss the following:

Staging investigations

To find out the extent of your prostate cancer, your urologist may arrange a CT scan, an MRI scan or a bone scintigram (or bone scan). Together with the Gleason grade found on the biopsies, these will determine what treatment is needed. Not all patients will require staging investigations before treatment.

Treatment options

Once the results of all the tests are available, your urologist will discuss what treatment options are available and what is best for you. This will take into account your age, general health, PSA level, Gleason grade and stage of the tumour.

Your urologist will help you decide whether treatment by surgery, hormones, chemotherapy or radiotherapy is best for you. It may be more appropriate for your cancer to be monitored closely and treated only of there are signs of progression (active monitoring).