Posted in: Prostate Cancer Treatment by Dr. Tarang Krishna Posted Date: 22 May, 2020
The protein Prostate-Specific Antigen, PSA full form, is released by both healthy and cancerous cells in the male prostate glands. It is mostly found in the semen and helps in keeping it in liquid form following ejaculation. A small amount of PSA is also released in the bloodstream, which rises as you get older, and the prostate grows more prominent. When there is an issue with the prostate, such as enlargement of prostate glands or growth of prostate cancer, the PSA level goes up. When it happens, it is a warning sign that you should follow up with your doctor.
What is a PSA Test?
The PSA test is the most frequently used blood test that measures the level of PSA circulating in the blood. The main goal of this screening is to diagnose prostate cancer. The higher your PSA count is, the more likely it is that you have active prostate cancer.
During the PSA test, a blood sample is taken from the arm and sent to a lab. The result often comes back within a few days. However, you must avoid intercourse and masturbation for 24 hours before your PSA test, as releasing semen can elevate your PSA levels.
How is the PSA Count Measured?
The PSA exists in the blood in two primary forms: complexed (CPSA, bound to other proteins) and free (fPSA, not attached). The standard PSA test measures the sum of CPSA and fPSA in the blood to detect prostate cancer. However, this test, by itself, cannot tell if the disease is 100% there.
Usually, the PSA count in the blood is reported as nanograms per millilitre (ng/mL). If the PSA level is above 4 ng/mL, doctors recommend undergoing a prostate biopsy to determine the presence of cancer in prostate glands. A prostate biopsy is a simple, 10-minute procedure in which the doctor extracts a small number of tissues from your prostate and sends it to the lab to test for cancer.
What can Lower the PSA Test Results?
In addition to prostate cancer, there are various reasons for high PSA levels, such as enlarged prostate, prostatitis, ejaculation before one or two days of the test, certain medications, and more. In any of these situations, the following medicines can help in lowering the PSA test results. However, you must consult your doctor or healthcare provider before you start taking any of the below drugs.
- Various drugs used to cure benign prostatic hyperplasia (BPH) or urinary infection, such as finasteride (Proscar or Propecia) or dutasteride (Avodart), can reduce PSA levels by about 50% within six to twelve months of use.
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Some herbal supplements contain plant-derived chemicals called phytoestrogens that have estrogen-like effects. These can also reduce the PSA count in your blood. Saw palmetto is another herb mainly used for BPH and enlarged prostate treatment.
What are the Usual Results for the PSA Test?
There is no specific average PSA level in the blood for a man at any age. The high PSA level and the average PSA level depends on many different factors unique to each man, such as age, ethnicity, family history, size of the prostate, and more.
The prostate gland gets bigger and releases more PSA as the age increases. So, a young man's PSA level tends to be a little lower than those of older men. Here is a PSA chart that shows what the normal PSA range should be according to the age of men.
Age
PSA Normal Range
40s - 0–2.5 ng/mL
50s - 0–4 ng/mL
60s - 0–4.5 ng/mL
70s - 0–6.5 ng/mL
Furthermore, many doctors consider 4.0 ng/mL and lower as a normal PSA level. Here are some PSA level guidelines:
- Safe: 0 to 2.5 ng/mL
- Safe in most men:2.6 to 4 ng/mL
- Suspicious: 4 to 10 ng/mL. This level might suggest a 25 per cent possibility of prostate cancer.
- Dangerous:10 ng/mL and above. You should immediately consult your doctor as there is a 50% chance of having prostate cancer.
What Causes Elevated PSA Levels?
Since the PSA is not specific to the prostate cancer but the prostate tissue, a high PSA level can be the result of many other common conditions. The factors that raise PSA levels include:
- Enlarged prostate –Some men may experience Benign prostatic hyperplasia (BPH) as they age. It is a condition which results in non-cancerous enlargement of the prostate, which elevates PSA levels.
- Prostatitis – This is an inflammation and infection of the prostate gland, which can make the PSA count increase.
- Urinary Tract Infection –UTIs are another common cause of a spike in the PSA levels.
- Ejaculation – This causes a significant rise in PSA level that may last up to 48 hours. That is why doctors advise avoiding ejaculation for a day or two before testing.
- Bicycle riding – Some studies found that when you ride a bicycle, the seat puts pressure on the prostate, which may increase PSA concentration for a short time.
- Urologic procedures – Certain urologic procedures, such as digital rectal examination, prostate biopsy, and cystoscopy may cause a rise in PSA.
- Medications – Taking medicines that increase testosterone levels can also result in the increase in PSA level for a short while.
- Age –PSA levels tend to increase as you get older, even if you have no prostate abnormalities.
When should you have your PSA Levels Tested?
If you choose to have your PSA levels tested, you must discuss the various pros and cons associated with prostate cancer screening with your doctor. Here are some general guidelines:
- Start around the age of 40 to 45 if you have a high chance of having prostate cancer due to various factors, such as a family history of prostate cancer, being African-American and more.
- If you are between 50 to 75, the chances of developing prostate cancer are higher. Thus, you must discuss the various risk factors and benefits of the PSA test with your doctor before getting tested.
How can you Prepare for the PSA Test?
Below are some steps you need to take before PSA testing to ensure accurate results:
- Ejaculation: Avoid ejaculation for 48-72 hours before the test as it could raise the PSA levels for a short time.
- Medications: Inform your doctor of the prescriptions or any other medicines, vitamins, and supplements you take. It is because certain drugs can result in falsely low or high results.
- Urinary Tract Infection: UTIs can cause inflammation of the prostate, which can raise the PSA count. So, if you had a recent Urinary Tract Infection, you must wait for a few months before getting tested.
- Digital Rectal Examination: Always perform a digital rectal examination after the PSA blood test. Doing it before can release PSA in your bloodstream and lead to false-positive results.
What is the accuracy of a PSA test?
The most significant drawback of the PSA test is its diagnostic inaccuracy. The elevated PSA is not always the sign of prostate cancer. Instead, it can be affected by other non-cancerous conditions, such as benign prostatic hyperplasia (BPH), prostatitis, etc. Studies show that 70% to 80% of men with high PSA level who have biopsy do not have prostate cancer. Conversely, about 20% of men detected with cancer have normal PSA count, i.e., less than 4 ng/mL. Furthermore, different testing equipment can reveal different PSA test results, resulting in confusion among the patients.
For these reasons, some experts are considering other ways of detecting prostate cancer, such as taking a man’s age into account, observing how a man’s PSA changes over time, measuring the level of free PSA, and more.
How is PSA Used to Detect Prostate Cancer at an Early Age?
Early detection of prostate cancer has resulted in a dramatic reduction in prostate cancer deaths in the past few years. Prostate-Specific Antigen (PSA) test and Digital Rectal Examination (DRE) are the two most common screening procedures used in finding prostate cancer at an early stage. In DRE, a doctor wears a lubricated glove and inserts a finger in the rectum to check for irregularities in the back area of the prostate. That is the area where most prostate cancers develop.
The increase in PSA count and abnormal DRE allows early detection of prostate cancer and enables the doctors to provide the definitive treatment. It further prevents the development of metastatic tumour and prostate cancer deaths.
How much does a PSA Test Cost?
The cost of the PSA test in India starts from Rs.200 and can go up to Rs3,000 depending on the location. This prostate test is covered by most insurance plans once a year, especially for men with age 50 and over.
How does PSA Testing Help in Pretreatment Staging of Prostate Cancer?
Accurate pretreatment staging is critical for managing prostate cancer. Staging helps in finding whether the cancer is localised (confined to an organ), or metastatic (has spread to other parts of the body). Hence, it results in the effective management and treatment of prostate cancer.
Once prostate cancer is detected through a prostate biopsy, it is assigned a tumour grade (based on the Gleason grading system). PSA tests, in a combination of prostate cancer grade, are then used to determine the additional tests required for cancer stages, such as bone scan, CT, and MRI.
- Patients with PSA levels lesser than 10.0 ng/mL are more likely to respond well to local therapy, such as prostatectomy or external beam radiation.
- Bone scan, used to detect whether the tumour has spread to the bones, is required only when high-grade prostate cancer is there, and the PSA level is more than 20.0 ng/mL.
- CT scan or MRI is recommended for men with high-risk clinically localised prostate cancer when the PSA count is more significant than 20.0 ng/mL.
What are the Limitations of a PSA Test?
There are various problems associated with the PSA test, such as:
- Early detection may not reduce the chances of dying from prostate cancer. The PSA test often finds slow, small, and non-serious tumours that are not life-threatening. Detecting such tumours is known as ‘overdiagnosis’, and treating them is called ‘overtreatment’. Overtreatment, whether with surgery or radiation, can expose you to various complications and harmful side-effects, such as erectile dysfunction, inability to control urine flow, infections, and problems with bowel movements. Also, finding tumour at an early stage may not help you if you have a fast-growing tumour that may have grown to other parts of the body before getting detected.
- The PSA results can be inaccurate. A positive effect means high PSA levels, but no cancer is present. It could create a lot of stress for you and can lead to various unnecessary medical procedures, such as prostate biopsy. A negative test, on the other hand, occurs when you do have cancer even though your PSA level is low. It may give you and your family a false sense of security and prevent you from getting the necessary treatment you require.
How are Researchers Trying to Improve PSA Testing?
Researchers are investigating new methods to improve PSA tests that can assist the doctors in discriminating between the aggressive, fast-growing tumours and the slow-growing ones. Some of these methods are:
1. PSA density of the transition zone
In this, the total PSA value is divided by the transition zone volume. The transition zone is the inner part of the prostate that surrounds the urethra. This zone is smaller in young men and gets more prominent as they age. According to experts, 20% to 25% of prostate cancer cases arise in the transition zone. It is why many scientists consider this a more accurate method of detecting prostate cancer in men with a PSA of 4 to 10 ng/mL.
2. Age-specific Reference Ranges for PSA
PSA levels are higher in older men than in younger men, even if there is no cancer. Many doctors suggest that the use of age-specific PSA reference ranges can improve the diagnostic accuracy of PSA tests. It is because it aids in increasing the sensitivity of PSA in younger patients by detecting tumours at an early age. Further, it improves the specificity of the PSA test in older men and avoids unnecessary biopsies.
3. PSA velocity and PSA doubling time
These two metrics help detect prostate cancer risk at an early age. PSA velocity is simply the rate of increase of PSA levels in the blood over time. It is expressed as ng/mL per year and can help in predicting a man’s PSA levels in the future. A high PSA velocity can be a sign of prostate cancer and may help detect fast-growing prostate tumours earlier.
PSA doubling time is the duration over which a man’s PSA level will increase two-fold. The less the PSA doubling time, the high is the risk of dying from prostate cancer.
4. The percent-free test
As discussed before, the PSA exists in two forms in the bloodstream – free PSA (moves around freely) and complex PSA (attached to blood proteins). This method checks the amount of free PSA in your blood that is not bound to other proteins compared to the total PSA level. Here, your free PSA is divided by your total PSA to determine the percentage of free PSA in your blood. The lower the percentage, higher is the risk of having prostate cancer. For example, a free PSA percentage of less than 10 per cent means there is a 50% chance of having prostate cancer.
Knowing your free PSA level might not give you an accurate answer about cancer, but it may help when considering whether you should go for a biopsy or not.
5. Urine PCA3 Test
It is a practical test that helps to discriminate between cancerous and non-cancerous PSA elevations. This urine test looks for a genetic marker that is present in 50% of the PSA-tested men with prostate cancer. Prostate Cancer Antigen 3 (PCA3) is a gene found in all prostate gland cells and causes them to release small amounts of specific proteins. Cancerous prostate cells are capable of producing this protein 60-100 times more than non-cancerous ones. When this happens, the extra proteins will release in your urine. And, if this test detects those proteins in your urine, it can be a sign of prostate cancer. The urine PCA3 test is used more often in men having:
- Negative biopsy
- Low PSA levels even if cancer is present
- High PSA levels and prostatitis
It is why the PCA3 test can reduce the number of unnecessary biopsies generated as a result of false-positive PSA test results. Further, what makes this method more accurate is that unlike PSA, PCA3 is not affected by non-cancerous conditions, such as prostate enlargement and infection.
About The Author
Dr. Tarang Krishna
Dr. Tarang Krishna, Director at Cancer Healer Center, is the perfect epitome of perseverance and dedication.
He has an impressive educational background to his credit. He completed his under-graduation in Medicine and Surgery from Pune, India and did his MD (Hom) from Agra University, India.Thesis on MD was on "Treatment of cancer" where he presented cases of almost 100 patients and the response of the medicines in the treatment of cancer. He then completed his Ph.d in Oncology from the United Kingdom and his thesis on the ‘Efficacy of Medicines in the Treatment of Cancer’ is greatly commemorated and honored.
He befittingly represents alternate medicine and has contributed significantly towards the development and research of immunotherapy.
Through his nationwide chain of “Cancer Healer Center” clinics he strives to offer superior cancer treatment, using immunotherapy.
