How Accurate Is The PSA Test In Detecting Prostate Cancer?

I am a 52-year-old man with a history of hypertension. My recent annual physical showed an increase in my PSA from .4 to 10.4. I have no symptoms of prostate problems. An exam of my prostate exhibited some small abnormality in shape but no other problems. I have an ultrasound and possible biopsy in a few weeks. I have recently had some testosterone treatments. How worried should I be?

The value of the PSA, a protein formed only in the prostate gland and formed more in cancerous than non-cancerous cells, can vary considerably based on age, race, size of the gland, and recent sexual activity. The level increases with age, and with benign prostatic hypertrophy or enlargement, which itself increases with age. African Americans are known to have on the average higher PSA levels than whites of the same age, and Asian men have on average lower levels than whites. Having prostatitis (inflammation of the prostate), having ejaculated, or having had a rectal prostate exam within a few hours before the test can also elevate the results.

As with most tests, there is no specific cutoff level at which one can say that you have or don’t have the disease being tested for. When the test first came out, the cutoff point was taken as 4 ng/ml. Recent articles have pointed out that at that level, only about 25 percent of the men actually had prostate cancer when tested further. This level is therefore now being adjusted for age and race. Unfortunately, as with all tests, there are also false negatives, and about 20 percent of diagnosed cases of prostate cancer are found in men with normal (less than 4 ng/ml) levels of PSA.

Your level of 10.4 ng/ml is high enough regardless of your age or race to merit further testing. I would also be concerned about the rapid rise in that level during the past year, assuming your prior PSA of 0.4 ng/ml was done approximately a year ago. Some experts use the PSA velocity, or the rapidity of increase, to help interpret an elevated value. An increase from 0.4 ng/ml to 10.4 would represent a high velocity. If you have had prostatitis however, the interpretation is less clear.

I don’t know whether your previous testosterone therapy could cause this degree of elevation in the absence of prostate cancer or prostatitis. However one of the concerns that doctors have about taking testosterone, or similar hormones like DHEA or hormones used for body building, is that they might stimulate, or speed up the development of prostate cancer. Your history of having taken testosterone would certainly make me urge you even more to have further evaluation.

The ultrasound you are scheduled for is almost certainly a transrectal one, in which the ultrasound probe is inserted into the rectum. This provides a very clear picture of the gland. Its total volume can be calculated and small nodules that might represent cancer can be seen. Needle biopsy using the ultrasound picture for guidance can be very precise. Even if your ultrasound shows no nodules though, I believe that at this level of PSA most experts would suggest that you have random, that is unguided, biopsies done.

Although it is disputed by some, most urologists believe that the cure rate of prostate cancer detected early by PSA is quite high. If indeed this is what your biopsy shows, you may wish to ask your urologist for the specific prognosis in your case.

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