Reasons For Low Free Psa Levels
Research has found several things that may play a role in your free PSA count.
Race and ethnicity. White and Asian men are more likely to have lower free PSA levels than African American men. White men who are not Hispanic also were more likely have low free PSA levels than those who considered themselves ethnically Hispanic.
Weight. Men who are overweight, particularly those who are very obese, tend to have lower free PSA levels.
Smoking. One study found that men who smoke or used to smoke have lower free PSA levels than those who never did.
Age. Younger men are more likely than those over 70 to have lower free PSA counts.
Enlarged prostate gland. This noncancerous condition, which can make it harder for you to pee, also may drop your free PSA count.
A low percentage of free PSAs to total PSAs also may be a sign that your cancer is more aggressive.
Controversy About The Psa Test
PSA tests are controversial because doctors and experts arent sure if the benefits of early detection outweigh the risks of misdiagnosis. Its also not clear if the screening test actually saves lives.
Because the test is very sensitive and can detect increased PSA numbers at low concentrations, it may detect cancer thats so small it would never become life threatening. Just the same, most primary care physicians and urologists do choose to order the PSA as a screening test in men over the age of 50.
This is called overdiagnosis. More men may face complications and risks of side effects from the treatment of a small growth than they would if their cancer was left undiagnosed.
Its doubtful those small cancers would ever cause major symptoms and complications because prostate cancer, in most but not all cases, is a very slow-growing cancer.
Theres also no specific level of PSA thats considered normal for all men. In the past, doctors considered a PSA level of 4.0 nanograms per milliliter or lower to be normal, reports the National Cancer Institute .
However, recent research has shown that some men with lower levels of PSA have prostate cancer and many men with higher levels of PSA dont have cancer. Prostatitis, urinary tract infections, certain medications, and other factors can also cause your PSA levels to fluctuate.
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Is Psa Testing Right For You
PSA testing may not be the right plan of action for everyone as there are some limitations with the test. Your doctor may recommend the test if you meet certain risk factors for prostate cancer such as:
- Age Men over the age of 50 are at a higher risk of prostate cancer.
- Race African-American men are at a higher risk of prostate cancer.
- Family genetics Men with a close family member, such as a father or brother, diagnosed with prostate cancer are at a higher risk of developing the disease.
- Genetics Inherited gene mutations increase the risk of cancer. The gene mutations associated with prostate cancer are BRCA1 and BRCA2.
- Diet Consuming a diet high in animal fats and low in vegetables may increase your risk of prostate cancer.
Talk to your doctor about your risks for prostate cancer and medical screenings that are right for you.
Recommendations For Psa Testing
According to a 2019 position statement from the European Association of Urology, a baseline PSA test in men aged 45 years at risk of prostate cancer should be used in combination with family history, ethnicity, and other factors to establish individualized screening frequency.
The American Urological Association and the American Cancer Society offer divergent recommendations on prostate-specific antigen screening. The AUA recommends baseline PSA testing, along with digital rectal examination , at age 40 for all men with a life expectancy of 10 years or more, with subsequent testing intervals determined on the basis of the PSA level and DRE results.
The ACS does not specify an age at which to pursue screening in asymptomatic men with a life expectancy of 10 years or more rather, the ACS advises clinicians to provide men with information on the risks and benefits of screening so the patient can make an informed decision. In addition, the ACS recommends that men whose initial PSA level is below 2.5 ng/mL can be screened every 2 years, but men with higher PSA values should be tested annually.
From these findings, the investigators concluded that potentially curable prostate cancer is not compromised when measuring PSA every other year in men with PSA levels of 2 ng/mL or less, as long as the DRE findings are normal.
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One Test Several Roles
Doctors use blood PSA levels for several very different purposes. The test is an extremely important way to diagnose prostate cancer in men who have symptoms or laboratory abnormalities that raise suspicion of the disease. PSA levels are also used to evaluate the results of prostate cancer treatment. Some doctors even use PSA readings to estimate the severity of benign prostatic hyperplasia , non-malignant enlargement of the gland. There is no controversy about these PSA tests but there is controversy galore about the most widespread use of PSA testing: screening for prostate cancer in men who are free of signs and symptoms of the disease.
What Should I Expect If Im Told I Have Elevated Psa
If your provider finds an elevated PSA level, youll have repeat tests to check your prostate. Many men with elevated PSA levels even those who have prostate cancer live long, healthy lives. Prostate cancer may not need treatment, depending on how slowly the tumor is growing. Keep up with your regular appointments and tests so your care team can keep tabs on your health.
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Normal Psa Levels By Age
For total PSA, the following values are considered normal
- 0-2.5 ng/mL for men aged 40-49 years
- 0-3.5 ng/mL for men aged 50- 65 years
- 0.0-4.5 ng/mL for men aged 60-69 years
- 0.0-6.5 ng/mL for men aged 70-79 years,
In women, total PSA should be under 0.002 ng/mL
Free PSA in the range of 0.2 to 5.0 ng/mL is normal in men with total PSA levels of 4.0-10.0 ng/mL. The following levels are considered normal by age in healthy men :
- 0.5 ng/mL for men 40-49 years old
- 0.7 ng/mL for men 50-59 years old
- 1.0 ng/mL for men 60-69 years old
- 1.2 ng/mL for men 70-79 years old
ThePSA Free/Total index should be > 25%
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Improving Sensitivity Of Psa Testing
Prostate-specific antigen testing with a cutoff of 4.0 ng/mL has a sensitivity of 67.5-80%, which implies that 20-30% of cancers are missed when only the PSA level is obtained. Sensitivity can be improved by lowering the cutoff or by monitoring PSA values so that a rise in PSA level of more than 20-25% per year or an increase of 0.75 ng/mL in 1 year would trigger performance of a biopsy regardless of the PSA value.
The specificity of PSA at levels higher than 4.0 ng/mL is 60-70%. Specificity can be improved by using age-adjusted values, PSA velocity , and the ratio of free PSA to total PSA . Another method is to adjust the PSA according to the size of the prostate or volume determinations of the transitional zone, which produces most of the PSA, and the peripheral zone, which produces less PSA but a majority of prostate cancers.
In the European Randomized Study of Screening for Prostate Cancer, Schroder et al studied a strategy for the early detection of prostate cancer that excluded digital rectal examination results and used a PSA cutoff of 3.0 ng/mL as the only indication for a biopsy. This protocol was compared with one in which a PSA level of 4.0 ng/mL or higher or the presence of a positive DRE or transrectal ultrasound was the indication for a biopsy. In a follow-up study, Schroder et al confirmed a substantial reduction in mortality from prostate cancer as a result of PSA testing.
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The Role Of Psa In Choosing The Best Treatment
If you have received a diagnosis of prostate cancer, your PSA levels can be used along with the results of other tests and physical exams and your tumors Gleason score to help determine which tests are needed for further evaluation and to decide on the best treatment plan. After treatment has begun, your PSA and other tests will be used to determine how well the treatment is working: The more successful the therapy, the lower the PSA.
What Does A High Psa Level Mean
High PSA levels could be a sign of prostate cancer or a different condition like prostatitis or an enlarged prostate.
Other things can affect your PSA level:
- Age. Your PSA will normally go up slowly as you get older, even if you have no prostate problems.
- Medications. Some drugs may affect blood PSA levels. Tell your doctor if youâre taking dutasteride or finasteride . These drugs may falsely lower PSA levels by half of what they should be.
If your PSA level is high, your doctor may suggest that you get a prostate biopsy to test for cancer.
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Transrectal Ultrasound With Prostate Biopsy
Transrectal ultrasound is most often used to examine the prostate. In a transrectal ultrasound, the health care provider inserts a transducer slightly larger than a pen into the mans rectum next to the prostate. The ultrasound image shows the size of the prostate and any abnormal-looking areas, such as tumors. Transrectal ultrasound cannot definitively identify prostate cancer.
To determine whether a tumor is cancerous, the health care provider uses the transducer and ultrasound images to guide a needle to the tumor. The needle is then used to remove a few pieces of prostate tissue for examination with a microscope. This process, called biopsy, can reveal whether prostate cancer is present. A transrectal ultrasound with prostate biopsy is usually performed by a doctor in a health care providers office, outpatient center, or hospital with light sedation and local anesthesia. The biopsied prostate tissue is examined in a laboratory by a pathologista doctor who specializes in diagnosing diseases.
Following Psa Levels During And After Prostate Cancer Treatment
A mans prostate-specific antigen blood level is often a good indicator of how effective treatment is or has been. Generally speaking, your PSA level should get very low after treatment. But PSA results arent always reliable, and sometimes doctors arent sure what they mean.
Before starting treatment, you might want to ask your doctor what he or she expects your PSA level to be during and after treatment, and what levels might cause concern. Its important to know that the PSA level is only one part of the overall picture. Other factors can also play a role in determining if cancer is still there, if it is growing, or if it has come back.
Its also important to know that PSA levels can sometimes fluctuate a bit on their own, even during or after treatment, so they may not always be a sign of what is actually happening with your cancer. Understandably, many men being treated for prostate cancer are very concerned about even very small changes in their PSA levels. The PSA level is an important tool to monitor the cancer, but not every rise in PSA means that the cancer is growing and requires treatment right away. To help limit unnecessary anxiety, be sure you understand what change in your PSA level might concern your doctor.
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Quality Control And Lab Safety
The decision to refer to urology will include the PSA value, history, examination, and patient preference. There is a direct correlation with age and serum PSA concentration, with a 3.2% increase per year, demonstrated in healthy 60-year-old males. Therefore, when utilizing serum PSA values, it is important to adjust for age. The 95 percentile PSA value is commonly used for abnormal reference range, which are as follows:
- Males 40-49 years: more than 2.5 ng/mL
- Males 50-59 years: more than 3.5 ng/mL
- Males 60-69 years: more than 4.5 ng/mL
- Males 70-79 years: more than 5.5 ng/mL
What Is A Normal Psa Test Result
There is no specific normal or abnormal level of PSA in the blood. In the past, PSA levels of 4.0 ng/mL and lower were considered normal. However, some individuals with PSA levels below 4.0 ng/mL have prostate cancer and many with higher PSA levels between 4 and 10 ng/mL do not have prostate cancer .
In addition, various factors can cause someones PSA level to fluctuate. For example, the PSA level tends to increase with age, prostate gland size, and inflammation or infection. A recent prostate biopsy will also increase the PSA level, as can or vigorous exercise in the 2 days before testing. Conversely, some drugsincluding finasteride and dutasteride, which are used to treat BPHlower the PSA level.
In general, however, the higher a mans PSA level, the more likely it is that he has prostate cancer.
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What Causes Prostate Cancer
Experts arent sure why some cells in the prostate gland become cancerous . Genetics appear to play a role. For example:
- Youre two to three times more likely to get prostate cancer if your father, brother or son has the disease.
- Inherited mutated breast cancer genes and other gene mutations contribute to a small number of prostate cancers.
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Men With Average Risk Should Talk To Their Doctor About Getting Their Psa Levels Checked Starting At Age 50
There are certain things that can increase your prostate cancer risk, including:
- Having a family history of the disease
- Being African American
- Knowing you have a genetic mutation associated with prostate cancer
If you have an average risk of prostate cancer, we recommend you start having conversations with your doctor about PSA screenings beginning at the age of 50 and continuing through 70. If your risk is low, your doctor may suggest less frequent screenings.
However, if you have a high risk of developing prostate cancer, your doctor may recommend earlier or more frequent PSA tests. For example, if your brother was diagnosed with prostate cancer, you may benefit from annual screening starting at 50.
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What Else Affects Your Prostate
Part of what makes it difficult to set a cutoff point is that there are numerous variables that can increase PSA levels. This can include:
- An enlarged prostate
- Some medication
- Some urologic procedures that affect the prostate
Other factors that can decrease your prostate-specific antigen levels include:
- 5-alpha reductase inhibitors
- Herbal mixtures taken as dietary supplements
- Long-term use of aspirin, thiazide diuretics, statins, and other medicines
Itâs important to understand that PSA levels can be low even if there is prostate cancer. Itâs worth talking with your healthcare provider about anything that might be affecting your PSA levels .
Psa Testing For Detection Of Prostate Cancer
The introduction of prostate-specific antigen testing into clinical practice has greatly increased the detection of localized prostate cancer and, by doing so, has decreased the diagnosis of regional and metastatic disease. PSA testing has had such a profound clinical effect that questions have arisen regarding the significance of the cancers that are being detected.
Stage, grade, tumor volume, and PSA testing are used to determine whether a prostate cancer is clinically significant or insignificant. However, there is no generally accepted precise definition for this distinction.
The goal of early detection of prostate cancer is to identify clinically significant cancers at a time when treatment is most likely to be effective. The risk of death from prostate cancer is significant in those with moderate- to high-grade tumors. This is especially true in younger men. Long-term survival is compromised when the cancer has spread beyond the confines of the prostate, into the regional lymph nodes, and to distant sites.
Several studies have shown that with a PSA cutoff of 4.0 ng/mL, clinically insignificant cancers are detected in fewer than 20% of men, but nearly 50% of all the cancers detected because of an elevated PSA level are localized, and these patients are candidates for potentially curative therapy. Only a small proportion of prostate cancers detected by PSA testing and treated with radical prostatectomy are low-volume and low-grade tumors.
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How Is The Psa Test Used In Men Who Have Been Treated For Prostate Cancer
The PSA test is used to monitor men after surgery or radiation therapy for prostate cancer to see if their cancer has recurred . If a mans PSA level begins to rise after prostate cancer treatment, it may be the first sign of a recurrence. Such a biochemical relapse typically appears months or years before the recurrence causes symptoms.
However, a single elevated PSA measurement in someone who has a history of prostate cancer does not always mean that the cancer has come back. Someone who has been treated for prostate cancer should discuss an elevated PSA level with their doctor. The doctor may recommend repeating the PSA test or performing other tests to check for evidence of a recurrence. The doctor may look for a trend of rising PSA level over time rather than a single elevated PSA level.
A rising trend in PSA level over time in combination with other findings, such as an abnormal result on imaging tests, may lead the doctor to recommend further cancer treatment.