What Does a Raised PSA Mean? Is It Cancer?

A raised PSA found at a routine check-up makes many men worry: “Do I have cancer?” In fact, most of the causes that raise PSA are not cancer. In this article we explain what PSA is, what makes it rise and which steps follow a raised result.

What is PSA, and what does it measure?

PSA (prostate-specific antigen) is a protein produced by the prostate gland that keeps semen fluid. A small amount passes into the blood and is measured with a simple blood test.

The key point here is this: PSA is specific to the prostate, not to cancer. The amount of PSA in the blood also rises when the prostate is enlarged, inflamed or irritated. For this reason, PSA is not a diagnostic test but a screening and monitoring test that helps decide whether further assessment is needed.

What should PSA be? Is there a normal value?

There is no single normal value that applies to everyone. For many years 4 ng/mL was used as the cut-off; however:

• Prostate cancer can also be found at values below 4,
• At values above 4, there is often no cancer.

PSA naturally increases with age and prostate volume. So rather than a single number, what matters is that the result is interpreted according to age, prostate size, previous values and the examination. How quickly the value rises over time is also taken into account.

What makes PSA rise?

• Benign prostate enlargement (BPH): An enlarging prostate produces more PSA. For details, see the enlarged prostate treatment page.
• Prostatitis (inflammation of the prostate): In acute prostatitis in particular, PSA can rise markedly and may take weeks to return to normal.
• Urinary tract infection
• Recent ejaculation
• Long bike rides or strenuous exercise
• Urological procedures: A catheter, cystoscopy and a prostate biopsy raise PSA.
• Inability to pass urine (urinary retention)
• Prostate cancer

Some medicines, on the other hand, lower PSA. The 5-alpha reductase inhibitors used for an enlarged prostate roughly halve PSA within a few months. In men taking these medicines, the result needs to be interpreted with this in mind; otherwise the real risk may be missed.

What should you bear in mind before a PSA test?

Avoiding factors that can raise PSA temporarily prevents unnecessary worry and tests:

• Avoid ejaculation for 2 days before the test.
• Do not go on long bike rides or do strenuous exercise in the days before the test.
• If you have signs of a urinary tract infection or prostatitis, postpone the test until after treatment and recovery.
• Do not have the test immediately after a procedure such as a catheter, cystoscopy or biopsy; ask your doctor how long to wait.
• If you take medication for an enlarged prostate, always mention the name of the medicine.
• For follow-up, use the same laboratory whenever possible; there can be small differences between different analysers.

Keeping all your previous PSA results with their dates allows the change over time to be interpreted correctly. The trend of the values over the years matters more than a single measurement.

My PSA is raised. Does that mean cancer?

No, it does not mean cancer on its own. In a large proportion of men found to have a slightly raised PSA, no cancer is found after assessment. On the other hand, a raised PSA is a finding that should not be ignored, because early-stage prostate cancer often causes no symptoms and is mostly picked up through this test.

What are free PSA and PSA density for?

Some of the PSA in the blood is bound to proteins, and some circulates freely. A low free-to-total PSA ratio slightly increases the likelihood of cancer, while a high ratio points more towards benign enlargement. This ratio is particularly helpful in the “grey zone” where PSA is slightly raised.

PSA density is calculated by dividing the PSA value by the prostate volume measured by ultrasound or MRI. A large prostate is expected to produce more PSA; a small prostate with a high PSA for its size is assessed more carefully. These calculations do not decide anything on their own, but they are used together with other findings to determine whether a biopsy is needed.

What steps follow a raised PSA?

In line with current guidelines, the assessment is usually carried out in the following order:

1. Repeating the test: PSA is measured again a few weeks later, if possible in the same laboratory and while avoiding factors that can raise PSA (ejaculation, cycling, infection).
2. Examination: The size and consistency of the prostate are assessed with a rectal examination.
3. Additional PSA calculations: The free-to-total PSA ratio and PSA density based on prostate volume can help to understand the risk better.
4. Prostate MRI (multiparametric MRI): Shows areas suspicious for cancer and helps to avoid some unnecessary biopsies.
5. Biopsy: If the MRI findings and risk assessment call for a biopsy, tissue samples are taken from the prostate with a needle. A definitive diagnosis can only be made with a biopsy.

If cancer is found on the biopsy, the treatment options are planned according to how far the disease has spread and the person’s general health. For details, see the prostate cancer page.

Who should have a PSA test, and when?

A PSA test should be done after its benefits and limitations have been discussed. Guidelines generally highlight the following groups:

• Men over 50
• Men with a family history of prostate cancer (father or brother): from the age of 45
• Men carrying certain inherited gene changes (for example BRCA2): at an earlier age

How often the test is repeated depends on the first PSA value and the individual’s risk.

When should you seek help without waiting?

A raised PSA on its own is not an emergency. However, if you have the following symptoms, seek medical help without waiting:

• Being unable to pass urine at all, or swelling and pain in the lower abdomen
• High fever, shivering and burning when passing urine (this may be acute prostatitis)
• Visible blood or clots in the urine
• New bone pain that does not go away, or weakness in the legs

When should you see a urologist?

It is advisable to see a urologist if your PSA is raised, if it has risen markedly compared with previous measurements, if prostate cancer runs in your family, or if you have symptoms such as a weaker urine flow, frequent urination or getting up at night to urinate. Bringing your previous PSA results with you makes the assessment easier.

Op. Dr. Mücahit Kabar sees patients in Bursa (Nilüfer), Turkey, at Özel Medicabil Nilüfer Hastanesi (weekdays 08:30–12:00, +90 444 8 112) and Özel Jimer Hastanesi (weekdays 13:00–17:00, +90 444 45 67). Appointments are booked through the hospitals’ online booking pages or appointment lines. Consultations are held in English or Turkish; the hospitals’ international patient departments can arrange interpreters for other languages. If you are travelling from abroad, you can send your questions and previous PSA results by WhatsApp to +90 541 622 54 82 before your visit. See the contact and appointment information for details.