Ask the Pharmacist

Q) I recently had a PSA test and was told my results were high. Does this mean I have prostate cancer?

A) Most of us have heard of a PSA test but many do not know what it really is or just what a high or low PSA level means.

PSA stands for prostate-specific antigen and it is a substance made by cells in the prostate gland (both by normal and cancerous cells) and while it is found mainly in the semen, small amounts are found in the blood as well.

For a PSA test, it’ll be a relief to some gentlemen (although perhaps not to all) that it is the blood levels that are checked in this test and compared to the so called norms. Just what constitutes a “normal” level really depends on a number of factors which is part of the reason why the PSA is far from a perfect test for detecting prostate cancer or anything else for that matter. In fact, many feel that there are no specific normal or abnormal levels of PSA and it is an indisputable fact that PSA levels rise and fall within each of us based on a multitude of factors.

Acknowledging all of that, doctors have traditionally looked at blood PSA levels above 4ng/ml as being some cause for concern and a reason to pursue further examination. This is based upon numerous studies that show that men with prostate cancer often seem to have PSA’s above 4 more often than not. But a cause for concern is not a reason for outright panic as cancer is far from a certainty regardless of how high the PSA level is.

There are men who are diagnosed with prostate cancer at levels well below 4 (which has led some experts to recommended further testing for younger men to be initiated at anything above a 2.5 reading) and many men who are cancer free at levels well past 4. Statistically, men with a PSA less than 4 (and a prostate that feels normal upon digital examination) have a 15% chance of being diagnosed with prostate cancer; those with a PSA between 4 and 10 have a 25% chance and those with a PSA above 10 are facing a greater than 50% risk.

Based on these numbers, it’s easy to see why the PSA test is still used but also why it is far from a perfect diagnostic tool. Reasons beyond cancer that might cause your PSA to be elevated include an inflamed or infected prostate (a condition called prostatitis), an infection somewhere within your urinary tract, a recent procedure on your prostate (such as a biopsy or a recent digital examination of your prostate), an extremely common non malignant condition called benign prostatic hyperplasia (i.e. the normal enlargement of the prostate that occurs with aging and may cause guys to need to urinate 6 times a night in an incredibly urgent manner).

Though benign prostatic hyperplasia can be a nuisance, at the end of the day it can be managed with exercises and/ or medicines and a bunch of everyday activities like riding a bicycle, engaging in sexual activity that includes ejaculation, and being exposed to warmer weather and isn’t going to shorten your time on this planet by a single day.

There are also a few drugs that can alter the PSA such as the statins (which are used to lower cholesterol), the NSAID’s (such as Advil and Aleeve which are used for pain and inflammation), the thiazide diuretics (designed to lower blood pressure) as well as some drugs that are designed to help with the normal age related enlargement of the prostate. Interestingly, all of these medications tend to lower PSA but whether this actually lowers your risk of prostate cancer is still an unknown (although data from the statins, at least, looks promising).

So, given all these non cancer causes for an elevated PSA, what should one do if a blood screening test comes in at over 4 (or perhaps 2.5 in a younger man)? Well most doctors agree that the first two steps are to order a second blood test of the PSA and to conduct the dreaded finger up the butt physical examination of the actual prostate.

The second (and perhaps a series of them) blood test is critical because the trend of your PSA levels (i.e. whether it is going up and if so, how quickly) is just as important as the actual numbers associated with them.

If the PSA level continues to rise or if the doctor feels a lump when conducting the digital exam, then there are a number of options that should be pursued. These include testing a urine sample in order to rule out an infection of the urinary tract as well as using imaging tests such as an x-ray, a transrectal ultrasound or cytoscopy.

If there are still concerns about the presence of cancer, the doctor will recommend a prostate biopsy which is a day surgery in which multiple samples of prostate tissue are collected by inserting hollow tubes into it which are then withdrawn and examined by a pathologist under a microscope. Complications from biopsies include pain, bleeding and the risk of introducing an infection. While most men who go on to the biopsy stage are concerned, they should know that only 25% who undergo this procedure are found to actually have cancer.

So, while the PSA test is far from perfect, the good news is that it is helpful and researchers are dedicating a lot of time and money in order to perfect these tests so that we miss less cancers and, just as importantly, don’t needlessly treat others for either non-existent cancers or ones that are so small and growing at such a glacial pace that they are unlikely to ever be a real issue.