PSA Test for Prostate Cancer

What is the PSA Test?

The most common screening tool for prostate cancer is the prostate-specific antigen (PSA) test. This is a simple blood test that measures the presence of PSA circulating in your bloodstream. This test is usually the first step in any prostate cancer diagnosis. However, the PSA blood test by itself cannot tell you if cancer is present.

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. A regular PSA test is one of the tools the doctor will use to measure if the cancer may have returned.

What is Prostate-Specific Antigen?

PSA is a protein produced by prostate cells that keeps semen in liquid form so that sperm can swim. A simple blood test can measure how much PSA is present in a man’s bloodstream. In almost all cases of prostate cancer the PSA level increases, which is why the PSA test is used as a screening tool.

What is a Normal PSA Level?

There isn't a specific "normal" PSA score. Elevated PSA score is one of the earliest symptoms of prostate cancer, but your PSA score is influenced by several factors, including age, race, nationality, recent activities, medications, and other health conditions that affect prostate health. It's possible to have a high PSA and still be cancer-free, and it's also possible to have cancer but still have a lower-than-average PSA score.

PSA Scores Increase As You Grow Older

An enlarged prostate is expected as you age. A healthy 60-year-old who has no evidence of prostate cancer will have a PSA score that increases by 3.2% each year (0.04 ng/mL)^[1]. This PSA levels chart summarizes a 1996 study's findings^[2] for average PSA scores in the United States:

Age Range	Average PSA	25-75% of Men	95th Percentile[3]
40-49 Years Old	0.72 ng/mL	0.4 - 1.1 ng/mL	2.5 ng/mL
50-59 Years Old	1.1 ng/mL	0.6 - 2.3 ng/mL	3.5 ng/mL
60-69 Years Old	1.5 ng/mL	0.8 - 3.5 ng/mL	4.5 ng/mL
70-79 Years Old	2.0 ng/mL	0.9 - 4.9 ng/mL	6.5 ng/mL

Different Studies, Different Findings

Studies have significantly different results based on patient nationality, race, and environmental factors^[4]. The chart above came from a 1996 study of Walter Reed Army Medical Hospital patients. It combines two different sets of data, as the findings show that Black patients had significantly higher average PSA scores than their white counterparts. It's also known that veterans have an increased chance of prostate cancer, further influencing these numbers.

In other words, finding a target PSA score that works for everyone, everywhere, is a challenge. In the past, doctors looked at the top 95% of scores to establish a cut-off (depending on your age, anything above 3.0-4.5 ng/mL was considered suspicious). More recently, knowing that no specific "good" or "bad" PSA number exists, recommendations for early detection have become more nuanced, looking at things like your age, risk factors, and previous test results.

Catching prostate cancer before it has a chance to spread can save your life. What matters most is knowing your risk and getting tested when recommended based on expert guidelines, rather than comparing your PSA score to the normal range across other patients.

What is a "Dangerous" PSA Score for my Age?

The National Comprehensive Cancer Network (NCCN) is a not-for-profit alliance of leading cancer centers, and they regularly publish expert guidelines for early detection of prostate cancer. This graphic summarizes their Clinical Practice Guidelines In Oncology for Prostate Cancer Early Detection (NCCN Guidelines®). Please use these guidelines to have a discussion with your doctor about your personal risk and make a plan for screening.

This chart helps explain PSA levels by age, and how scores should be interpreted differently based on your race, family history, past test results, and other factors.

• If you are between ages 40 and 75, and
  • Are Black/African American, and/or
  • Have a family history of cancer and/or a known genetic mutation that increases the risk for prostate cancer
    • Discuss the risk and benefits of prostate cancer screening with your doctor
    • Have a baseline PSA and strongly consider a baseline digital rectal exam (DRE)
    • If PSA less than 1 ng/mL and DRE normal (if done), repeat testing every 2 - 4 years
    • If PSA 1 - 3 ng/mL and DRE normal (if done), repeat testing every 1 - 2 years
• If you are between ages 45-75, and are at average risk:
  • Discuss the risk and benefits of prostate cancer screening with your doctor
  • Have a baseline PSA and strongly consider a baseline DRE
  • If PSA less than 1 ng/mL and DRE normal (if done), repeat testing every 2 - 4 years
  • If PSA 1 - 3 ng/mL and DRE normal (if done), repeat testing every 1 - 2 years
• If you are over age 75
  • Talk with your doctor about if prostate cancer screening should continue
  • If PSA less than 4 ng/mL and DRE normal (if done), repeat testing in select patients every 1 - 4 years
  • If PSA greater than 4 ng/mL or a very suspicious DRE, talk with your doctor about further testing and follow-up

Click here to download the PSA levels recommendations chart in image, PDF, or print format.

How Do I Understand my PSA Test Results?

See the above “Prostate Cancer Early Detection: Age Recommendations and PSA Levels Chart” for more information on understanding your PSA level. In general, these PSA level guidelines may help when consulting age-specific ranges and recommendations with your doctor:

• Younger than 49 and have a PSA score higher than 2.0 - 2.5 ng/mL.
• Ages 50-75 and have a PSA over 3.0 - 3.5 ng/mL.
• Older than 75 with a PSA above 4.0 ng/mL.

What if my PSA level is high?

You and your doctor can explore several options if your PSA is high. One option is to have a second PSA screening; recent research has shown that a second screening can improve the accuracy of an abnormal result. A digital rectal exam (DRE) can also provide more information, and a biopsy can confirm the presence or absence of prostate cancer. However, there are several other reasons why a PSA result might be high, including advanced age, ejaculation within the past 24 hours, and recently riding a bicycle.

If you have an elevated PSA, talk with your doctor about your activities and your health. Additional tests may also be recommended.

What if my PSA level is low?

In general, a low PSA is a good result. However, there are some reasons a PSA 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 bloodstream). Be sure to discuss these with your doctor.

What if my PSA is rising quickly?

The rate of yearly increase in the PSA level is known as the PSA velocity. An abnormally high PSA velocity can be a sign of prostate cancer, so it's one measure of risk that your doctor will use to consider next steps. This can be especially useful to find prostate cancer in early stages before the cancer has left the prostate.

What if I’ve Had Prostate Cancer Treatment, and my PSA Levels are Rising?

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.

What Additional Tests May be Needed?

A biopsy will be needed to confirm whether prostate cancer is present or not. There are additional tests that can give your doctor more information on how to determine the probability of both finding cancer during a biopsy and determining how aggressive that cancer is likely to be.

While none of these tests are conclusive on their own, when performed in addition to a PSA test, DRE, and a biopsy, they can provide each patient with more information about their specific cancer and can aid in both the diagnosis and decision on treatment. Read more about additional testing.

What is the Latest Information on PSA Screening Recommendations?

The latest NCCN recommendations are covered above in the Prostate Cancer Early Detection: Age Recommendations and PSA Levels Chart.

In 2012, the U.S. Preventive Services Task Force (USPSTF) assigned the PSA test a “D” rating. This meant that the USPSTF concluded the harms that resulted from PSA testing, such as unnecessary biopsies and negative treatment side effects, outweighed the benefits of finding and managing the disease early. This recommendation did not include exceptions for men at increased risk of developing the disease, such as Black or African American men, those with a family history of the disease, and those with BRCA gene mutations. The USPSTF recommendation is important as it guides primary care physicians in preventive care and can impact insurance coverage and reimbursement for screening. Prior to its “D” rating, the PSA test had an “I” rating, meaning the USPSTF concluded there was insufficient evidence to assess the pros and cons of testing.

In 2018, the USPSTF updated their recommendation on PSA screening, assigning the PSA test a “C” rating for men ages 55 to 69 (the test still has a “D” rating for men ages 70+). This was in response to research demonstrating the benefits of PSA screening (such as the European Randomized Study of Screening for Prostate Cancer), an increase in the number of men choosing active surveillance, and advocacy efforts.

This means that the USPSTF recognizes a small potential benefit of PSA testing and recommends that men make individual decisions about whether or not to get tested after discussing the risks and benefits with their doctors. Like the 2012 recommendation, this update does not include specific language for men at increased risk.

The National Comprehensive Cancer Network® (NCCN) and ZERO strongly recommend that men should be fully educated about prostate cancer, should know their options for early detection, and should have access to the tests we have available now. Researchers, with support from organizations like ZERO, are working every day to improve prostate cancer screening, but for now, we must use the tools we have. A PSA test score is an important part of making a decision on how best to determine a prostate cancer diagnosis and/or treatment pathway. Learn more about ZERO's advocacy efforts in early detection and access to PSA screening.

How Can I Get a PSA Test?

Talk to your primary care doctor or urologist about receiving a PSA test in their office. If you do not have a doctor or insurance (or if your insurance does not cover PSA screening), take a look at ZERO's free PSA screening search tool and see if there are sites near you where free testing may be available.

References

1. Oesterling JE, Jacobsen SJ, Chute CG, Guess HA, Girman CJ, Panser LA, Lieber MM. Serum prostate-specific antigen in a community-based population of healthy men. Establishment of age-specific reference ranges. JAMA. 1993 Aug 18;270(7):860-4.
2. Studies have found differences based on where men lived, including ones from the Mayo Clinic (MN), Walter Reed Army Medical Center (MD), Southeastern U.S., Japan, Taiwan, Iran, and China.
3. David MK, Leslie SW. Prostate Specific Antigen. StatPerls[Internet]. 2022 Nov 10; referenced online at https://www.ncbi.nlm.nih.gov/books/NBK557495.
4. Morgan TO, Jacobsen SJ, McCarthy WF, Jacobson DJ, McLeod DG, Moul JW. Age-specific reference ranges for serum prostate-specific antigen in black men. NEJM. 1996 Aug 1;335(5):304-10.