If your doctor recommends a prostate specific antigen (PSA) test and yours comes back elevated, you might be tempted to panic.

Don’t, says Dr. Brandon Craven, a urologist at Novant Health Urology - Kimel Park in Winston-Salem, North Carolina.

If you read no further, understand that:

  • A single PSA test doesn’t indicate that you have prostate cancer.
  • A high PSA test can mean something other than prostate cancer.
  • Screening for prostate cancer and interpreting your screening should be done in partnership with a urologist you trust.
  • If you have prostate cancer, you have options about how to move forward with diagnosis and treatment.

Advanced treatment for your prostate cancer.

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First: what is a PSA test?

Dr. Brandon Craven

A PSA test is one way to screen for prostate cancer. A technician draws your blood, and the laboratory measures the prostate-specific antigen (a protein produced by the prostate gland) in your blood. It might be included in your annual lab work.

PSA is measured in nanogram per milliliter. There isn’t a cut-off point that indicates “cancer” or “cancer-free,” but as your PSA level increases, it becomes more likely that you have prostate cancer. However, other conditions can cause a high PSA level as well.

Your doctor will interpret your results based on your age, the amount of PSA in your blood, any past PSA tests you have had, and other factors, including your race/ethnicity and previous prostate conditions you may have had.

What if my PSA level is high? Do I have cancer?

Not necessarily.

“A single PSA test is a slice in time. We don't make medical decisions on a single test, especially because PSA can have a lot of random variation in its measurement,” Craven said.

Riding horses or motorcycles, cycling, and ejaculating three to four days before the test can all temporarily raise your PSA levels. Recent medical procedures or illnesses can impact your PSA level as well. Your doctor will consider these when interpreting your results and will plan a retest as needed.

If your PSA level is still high after a re-test, you and your doctor will explore why.

What are the most common reasons for a high PSA level?

The most common reason for a high PSA level in Craven’s patients is an enlarged prostate (also called “benign prostatic hyperplasia”). Patients experiencing this might need to urinate frequently or with urgency and may notice a weak stream when they urinate. Or they may not have noticed anything at all.

“The symptoms often occur over decades, and most men minimize their symptoms,” Craven said. “They have downplayed it for so long that they wouldn’t admit it. They just think it’s a part of aging.”

If you notice changes in your urination, Craven said, it’s important to mention it to your provider, since an enlarged prostate can be treated with medication. Reducing the prostate size will make you feel better and will also help you and your doctor more accurately assess your prostate cancer risk.

Other common causes for a high PSA level are a prostate infection or urinary tract infection. And some patients don’t empty their bladder completely when urinating, which can cause a high PSA level. These can all be treated with medication.

If these conditions have been ruled out, and your second PSA test is still high, your urologist will complete a digital rectal exam, inserting a lubricated and gloved finger into your rectum to check for abnormalities – like lumps – around the prostate.

Even if the digital rectal exam is normal, prostate cancer is still a concern, so Craven said “so we come up with plans for next steps. It’s a very individualized thing depending on the patient, risk factors, life expectancy, and their concerns and desires.”

New testing method offers answers: MRI fusion biopsy

Your urologist found something suspicious – what’s next?

If your PSA and digital rectal exam are both abnormal, your urologist may want to take tissue or cell samples from selected areas of your prostate and test them in a laboratory to check for cancer. This process is called a biopsy. A prostate biopsy lets your urologist know whether you have prostate cancer, how advanced it is, and how to treat it.

A newer method – called MRI fusion biopsy – gives your urologist the real-time images they need to collect samples from every area of concern in the prostate.

In this two part-test, you first have a prostate MRI. Then, your doctor will numb you and insert a small ultrasound probe into your rectum. Guided by the detailed images from the MRI and the real-time ultrasound pictures – which are “fused” together by a computer program to create a very detailed picture – your doctor collects tissue samples from suspicious areas of your prostate.

Studies show that compared to previous biopsy methods, MRI fusion biopsy is more targeted, which means it has a higher likelihood of detecting cancer. When cancer is detected earlier, treatments can be started earlier and cancer is less likely to progress. MRI fusion biopsy is generally covered by most insurance companies.

Why is it so individualized?

Prostate cancer is the second most common cancer among men in the United States, according to the Centers for Disease Control and Prevention.

But because prostate cancer is typically slow-growing, treatment is not always advised. Craven explained, “This disease is very common, and we can alter the outcome, but only in men with at least 10 more years of life expectancy. For men 75 and older, or men who have less than 10 years of life expectancy, we won’t necessarily make him live longer by treating.”

For older patients, knowing more about their possible cancer may be stressful, since treatment may not be recommended depending on their age and the progression of their cancer. For younger patients, treatment will often be recommended, but it comes with side effects. These can include loss of urinary control (also called “incontinence”) which generally resolves within six months, and erectile dysfunction, which Craven said resolves on its own in about half of men and can be resolved with treatment in the other half.

For either group, these conversations are challenging. Because sexual health is important to most of us, Craven said, the potential of having prostate cancer is particularly scary.

“For a lot of men, this kind of strikes at the core of who they are. They hear horror stories of other men who had treatment, lost erections, lost continence – and that’s what's going through their mind,” Craven said. “Very few men know someone who has died of prostate cancer, so it’s not death they fear. It’s loss of function they fear. That's what's going through everybody's mind. ‘Do I really want to know that I have cancer?’”

What should I walk away knowing?

If you have had a high PSA score – or, if you haven’t yet begun screening for prostate cancer, but are in your mid-40s to 60s and have risk factors like being African American and/or having a family history of prostate cancer – it’s time to find a urologist to walk you through your options.

If you are in your 70s or later, you may still want to talk with a urologist about whether screening is recommended.

It’s important to find a urologist you feel comfortable with, Craven said, especially since the topics of urination, sexual health, and prostate cancer can all be uncomfortable to talk about. This may involve visiting more than one urologist to find the right match.

“Prostate cancer screening and treatment is the single most difficult thing in urology, and the single most individualized thing in urology,” Craven said. “It’s a long-term process and it’s important to get the right person – someone who will sit and talk to you, and you trust that they're going to do what’s in your best interest.”