Question: I am a 59-year-old man in good health. About two years ago my PSA level went from below four to 7.6 in a year's time. I went to a urologist who did an ultrasound and biopsy. Pathology results were negative and the report said my condition was atrophy and mild prostatitis.
During the next six months, a PSA check continued to rise above 11. Another biopsy was performed with the same results.
At the next checkup at six months, the PSA was up to 12.5. I had the same results with the third biopsy. At the last check in June, the PSA went down to 7.9 and free PSA went from nine to 13 percent. The only drug I took during this period is Tegretol for trigeminal neuralgia. More recently, I started taking Lipitor. I would appreciate any thoughts on my fluctuating PSA level. Many thanks, Allan
Dear Allan, It seems like you have been well exposed to the dilemma concerning elevated PSA and negative pathology on ultrasound-guided prostate biopsy. Urologists do not have a clear-cut answer as to how many ultrasound-guided biopsies need to be done for progressively elevating PSA.
One can conceivably perform a biopsy every six months and still not obtain any evidence of cancer. In fact, the yield of a positive biopsy for prostate cancer becomes less frequent with each subsequent biopsy.
Although a negative cancer report is good, the question remains about the elevated PSA: should the biopsy be repeated or ignored? It is frustrating not only for the patient, but also for the patient's physician.
It's important to realize that prostate cancer is not the only reason that a PSA test is elevated. Other causes include a urinary tract infection, prostatitis and BPH (enlargement of the prostate that occurs with aging).
However, prostate cancer is the most worrisome possibility. This is why an ultrasound-guided prostate biopsy is performed. As you probably know, the prostate biopsy only samples a portion of the prostate and does not indicate whether there might be cancer in adjacent cells that were not biopsied. Therefore, it's somewhat of a judgment call.
It sounds like you may have chronic prostatitis as evidenced by your prostate biopsy. This would explain the fluctuating PSA level. It is important that you still have your PSA level followed by your urologist and follow his/her recommendations.
Elevated PSA, Negative Biopsies
Question: I'm 55 years old and have an elevated PSA. My total PSA rose from 1.4 to 2.6 in one year, and then from 3.4 to 4.83 in the next six months. My free PSA is 5 percent and ultrasound and needle biopsies were both negative.
How serious is this? Are there other causes for this elevation other than prostate cancer or is that pretty much a certainty? Are there false positives in this range? I'm scheduled for another ultrasound next month. Thanks, Bill
Dear Bill, There are many parameters to help determine if a patient should have a prostate biopsy. It would be important to know if you have a family history of prostate cancer and what your past prostate biopsy reports have shown. If they indicate anything other than benign prostate hypertrophy (BPH), I would recommend another biopsy. There are also different areas of the prostate that can be biopsied.
It is mainly the transitional zone that harbors prostate cancer. By age-related criteria, your PSA is on the high side. The velocity, or rise in your PSA related to time, is cause for concern. Your free PSA range indicates the need for another biopsy.
Studies have shown that 20 to 25 percent of patients with a PSA between 4-10 ng/ml. will have cancer.
Based on your age (considered young by a urological measure), I would agree with your doctor's decision to perform another biopsy, perhaps doing more than the standard number of samples and also taking a sample from the transition zone, if this has not already been done.
If your follow-up biopsy is negative, you should continue to follow your PSA closely.
If there is not a significant rise, a fourth biopsy may not be indicated. It is possible that you have a falsely elevated PSA, if you have had infections of the prostate.
However, with the multiple draws over the years, the elevation is most likely accurate. An elevated PSA does not mean you have cancer but merely suggests that you are at increased risk and might need a biopsy. Another parameter you could ask your urologist to look at is PSA density since patients with very large glands tend to make more PSA. If this is the case, it would provide some reassurance for you.
Family History, Elevated PSA, Negative Biopsies
Question: My PSA rose from 5.0 in June 2007 to 7.0 in November 2007 to 10.3 in March 2008 to 18 in June of 2008. I have no PSA history before June 2007. My free PSA was 10 percent in June 2008. Ultrasound and needle biopsies after all four PSA tests were negative.
My prostate is enlarged but there is no reduction in urinary flow. There is no indication of a urinary tract infection or prostatitis. I am aware that an elevated PSA can be the result of an enlarged prostate but would it be as high as 18?
I am 50 years old and there is a history of prostate cancer in my family, affecting my father and his two brothers. Is there a correlation with the rate of change of the PSA and prostate cancer?
I am scheduled for another PSA and free PSA test but I am at a point of not wanting to have the test or know the results. I think I might be better off not knowing since this is weighing heavily on my mind. Thanks for any information you can provide, John
Dear John, PSA (Prostate Specific Antigen) is an important tool used by urologists to detect prostate cancer. A PSA level of greater than 4.0 ng/ml is associated with prostate cancer. Recent research efforts have been directed at assessing the rate of rise in PSA over time as well as evaluation of free PSA.
It is currently felt that a rise in PSA of greater than 0.75 ng/dl in one year or a rise of greater than 20 percent over two years suggests cancer.
There are several factors that can falsely elevate the PSA, including urinary tract infections, foley catheterizations, recent prostate biopsy (less than six weeks prior to the PSA test) and a severely enlarged prostate.
A prostate biopsy is performed when the PSA is greater than 4.0 ng/dl to evaluate for prostate cancer. In your case, the rapid rise in your PSA was appropriately evaluated with a biopsy. In the absence of infection or other causes of falsely elevated PSA, a repeat biopsy is wise.
You are young and apparently otherwise healthy. Early detection of a cancer would result in a very high chance of cure. Some men undergo three or more biopsies before cancer is detected.
It is worth the effort because the cure rate is quite high when detected early in the course of the disease. A family history of prostate cancer is important also. A repeat PSA and/or biopsy is imperative in your case.
