Education about prostate cancer risk and testing is part of a routine annual exam with a man’s physician. A general practitioner or an urologist can perform a full prostate cancer exam. This includes a PSA blood test and digital rectal exam, also called a DRE.
A Prostate Specific Antigen (PSA) test measures the level of PSA in the blood. PSA is a substance made by the prostate. The levels of PSA in the blood can be higher in men who have prostate cancer. The PSA level may also be elevated in other conditions.
A Digital Rectal Exam is a test that is done when a doctor or nurse inserts a gloved, lubricated finger into the rectum to estimate the size of the prostate and feel for lumps or other abnormalities.
Watch our new video about early detection of prostate cancer featuring prostate cancer experts.
The Discussion About the PSA Test
The U.S. Preventive Services Task Force (USPSTF) recommends against testing men for prostate cancer with the PSA test. This recommendation is important as it guides primary care physicians in preventive care and can impact insurance coverage and reimbursement for the test. Click here to learn about ZERO’s advocacy efforts in early detection.
This decision was made because the USPSTF believes that there is no a life saving benefit in the population when using the test. They claim that more harm comes to men from biopsies and negative treatment side effects than benefit in finding and managing the disease. Unfortunately they do not even support use of the test in men at increased risk, such as African American men and those with a family history.
We believe men should be informed about their options for testing and have access to the tests we have available now. Researchers, with support from organizations including ZERO, are working every day to find a new and better test but for now, we must use the tools we have.
Prostate Specific Antigen
The PSA is a protein produced by prostate cells. It is present in the bloodstream and the amount present can be measured with a simple blood test. The PSA keeps semen in liquid form so that sperm can swim. When a man has prostate cancer, his PSA level increases. This level is tested with the PSA test.
The PSA test measures the amount of PSA in your blood at the time the blood is drawn. The levels of PSA can rise due to a number of reasons, including cancer. The PSA test cannot tell you if cancer is present, when PSA is elevated it is a warning sign and you should follow up with your doctor.
The PSA test is also used to track the effects of prostate cancer treatment such as surgery, radiation, hormone therapy and chemotherapy. When a man has treatment for prostate cancer, his PSA level will drop significantly. Regular testing with PSA is one of the tools the physician will use to measure if the cancer has returned. When PSA levels rise to a certain threshold after prostate cancer treatment, this is known as biochemical recurrence. This means that some cancer cells have survived and are producing PSA. If this happens, the doctor will order additional tests and make recommendations for additional treatment.
Despite controversy about the PSA test, the National Comprehensive Cancer Network (NCCN) and ZERO – The End of Prostate Cancer strongly recommend a man should be fully educated about prostate cancer and know his options for early detection. A PSA test score is an important part of making a decision of how best to determine a prostate cancer diagnosis and or treatment pathway.
PSA Screening Guidelines
The guidelines below are adapted from the NCCN's Clinical Practice Guidelines, Prostate Cancer Early Detection. Please use these guidelines to have a discussion with your physician about your personal risk and make a plan for testing.
Age 40 – Talk to your physician about testing and your personal risk.
Age 45 – 49 – Have a baseline PSA and DRE
If your PSA is above 1 ng/mL, repeat at 1 – 2 year intervals until 50
If your PSA is below 1 ng/mL repeat PSA at 50
Age 50 – 70 – If your PSA is below 3 ng/mL, repeat testing at 1 – 2 year intervals
Age 70 and over – Talk with your physician and assess your general health to decide together if you should continue routine PSA screening
Click here to view the NCCN screening guidelines. You will need to create a free log in to access the document.
General PSA level guidelines
- 0 to 2.5 ng/mL is considered safe
- 2.6 to 4 ng/mL is safe in most men but talk with your doctor about other risk factors
- 4.0 to 10.0 ng/mL is suspicious and suggest the possibility of prostate cancer
- 10.0 ng/mL and above is dangerous and should be discussed with your doctor immediately
Age-specific PSA ranges
These reference ranges refer to using different PSA levels to help the physician make a recommendation for a biopsy. The age ranges are as follows:
- 40-49: 2.5
- 50-59: 3.5
- 60-69: 4.5
- 70 and up: 6.5
PSA level and chance of prostate cancer
Chance of having prostate cancer
Understanding a High PSA
There are several avenues to consider if a PSA is high and research continues develop more options every day. One should always have a Digital Rectal Exam (DRE), along with the PSA and/or an annual exam as it can detect prostate cancer or prostate problems that a PSA may miss.
Understanding a Low PSA
In general, a low PSA is a good result. However, there are several reasons a PSA test level may be artificially low including taking statins to lower cholesterol, anti-inflammatory drugs and obesity (body fat decreases the amount of PSA circulating in the blood stream). Be sure to discuss these with your doctor.
In addition to prostate cancer, there are other reasons for an elevated PSA:
- Advanced age
- Injury to pelvic region or prostate
- Riding a bicycle
- Sex (within 24 hours)
- Supplements that effect testosterone
- Urinary tract infection
If you have an elevated PSA, talk with your doctor about your activities and your health.
Annual changes in PSA test results is a method doctors use to determine the risk of prostate cancer as PSA can rapidly rise in men who have prostate cancer. It can be especially useful to find prostate cancer in early stages before the cancer has left the capsule of the prostate.
Research shows that an increase of .75 ng/mL over a year is an early indicator of prostate cancer if a man has a total PSA result between 4.0 and 10.0 ng/mL. Further, an increase of 2.0 ng/mL over a year period predicts a higher likelihood of death due to aggressive prostate cancer.
Research is also showing PSA velocity may be able to predict survivability from prostate cancer as men with a PSA increase of .35 ng/ML or less over a year have a 92 percent survival rate compared to PSA increases of more than .35 ng/mL over a year have a 54 percent survival rate.
Prostate Health Index
The Prostate Health Index is a new test to be used for the detection of prostate cancer. This test was only recently approved in the US and it is simple blood test that combines three tests in one. Research has shown that the test is better at detecting prostate cancer than the traditional PSA test. The test also predicts the likelihood of progression during active surveillance.
Because this test is very new, it is possible your physician has not heard of it yet. If you are interested in the test, talk with your doctor and discuss your risk, the test, and how to use the information from the test. Click here for research about the test.
Digital Rectal Exam (DRE)
A DRE is a routine procedure as part of an annual physical exam with a doctor. The physician briefly feels the surface of the prostate for any abnormalities by inserting a gloved and lubricated finger into the rectum for a several seconds.
The DRE is used to help diagnose prostate cancer – even when a PSA test is not high – and for other prostate problems such as benign prostatic hyperplasia (BPH) or prostatitis.
A DRE is performed without using any medication because the test is generally not painful and only takes a few minutes to complete. All clothes below the waist will be removed. There are several positions your doctor might ask you to take. Most likely the patient will either stand and bend forward at the waist or lie on their side on an examination table with knees pulled up to their chest in the fetal position.
During this test the doctor is feeling for bumps, soft or hard spots or other abnormalities on the prostate. If the prostate is enlarged there may be some discomfort during the examination and the urge to urinate may be present.
Most likely there will be no negative side effects from the test but it is possible to experience some rectal bleeding, particularly if hemorrhoids or anal fissures are present. Be sure to tell the physician or nurse if you are having any side effects.