What Women (and Men) Need to Know About Prostate Cancer Screening: Part 3

PSA Numbers and How to Make Sense of Them

What should the PSA level be?  Before we look at some numbers, please note:  if a man’s PSA is higher than these numbers, that doesn’t necessarily mean that he has prostate cancer; there are other factors that can raise PSA, which we will cover briefly.  I have much more about PSA here, and of course, in the book. 

• For men in their 40s and 50s: A PSA score greater than 2.5 ng/ml is considered abnormal. The median PSA for this age range is 0.6 to 0.7 ng/ml.
• For men in their 60s: A PSA score greater than 4.0 ng/ml is considered abnormal. The normal range is between 1.0 and 1.5 ng/ml.
• An abnormal rise (the rate and speed of change in PSA is called PSA velocity): A PSA score may also be considered abnormal if it rises a certain amount in a single year. For example, if a man’s PSA score rises more than 0.4 ng/ml in a single year, he needs to find out why.  If his PSA is going up and down but is still higher than it should be, he needs to find out why.

Men: If you are in your 40s and your PSA level is greater than 0.6 ng/ml, or if you are in your 50s and your PSA is greater than 0.7, you should have your PSA measured at least every two years.  If your PSA is below this, you may be able to wait as long as five years for the next test.

In older men, benign enlargement of the prostate (called BPH) can also raise the PSA number.  BPH is very common: it’s in 50 percent of men in their 50s, 60 percent of men in their 60s, 70 percent of men in their seventies, etc.  Note:  Drugs to treat BPH can artificially lower PSA by as much as half.  Taking a 5-alpha-reductase inhibitor, such as finasteride (Proscar) or dutasteride (Avodart) to treat BPH, or the drug Propecia, used to deter hair loss (a low-dose form of finasteride) can artificially lower PSA.  If a man has been taking one of these drugs for a short period of time, his PSA number should be doubled.  If he has been taking it for five years or longer, his PSA should be multiplied by 2.5.  Don’t just take that low score at face value.

Here are more PSA numbers from the book,, adapted from the Journal of the American Medical Association:

How many men my age have this PSA level?

2.5 or lower:  88 percent of men in their 50s, 75 percent of men in their 60s, and 61 percent of men age 70 or above.

2.6-4.0:  8 percent of men in their 50s. 14 percent of men in their 60s, and 18 percent of men age 70 or above.

4.1-9.8: 3 percent of men in their 50s.  9 percent of men in their 60s, and 16 percent of men age 70 or above.

10 or higher:  1 percent of men in their 50s.  2 percent of men in their 60s, and 5 percent of men age 70 or above.

All of this said, a PSA score on its own is not enough, because other things can raise PSA.  This is why getting that baseline and then watching what PSA does over time is so important.  This is PSA velocity:  watching what PSA does.

What else can raise PSA?

             Here’s a tip:  Get the PSA blood test done before the rectal exam at the annual physical.  The rectal exam, when the doctor pokes the prostate to check for any signs of hardness or lumps, can cause PSA to be released into the bloodstream – artificially raising the PSA number.  (Fun fact: what’s the prostate supposed to feel like?  Feel the pad at the base of your thumb.  The prostate should feel kind of squishy like that.)

            Similarly, so can having sex.  Therefore, a man should avoid sexual activity for three days before the blood test.  

Prostatitis can also raise PSA, sometimes to high levels.  This is not cancer; it’s inflammation in the prostate and it is treatable.  I have good information about prostatitis and pelvic pain syndrome here.

Second-Line Tests Shed Light in the Darkness!

Fortunately, there are “second-line” blood and urine tests that can help figure out if a raised PSA number is coming from BPH or prostate cancer.

I’ve got much more about these tests here, but briefly:  Nuanced tests such as the 4K score or Prostate Health Index (PHI) look at “free PSA.”  PSA comes in several different forms.  Free PSA measures whatever PSA in the blood that is not bound to proteins.  As Johns Hopkins urologist H. Ballentine Carter, M.D., was fond of saying, the higher percentage of PSA that is free, the more likely you are to be free from cancer.  This test provides context:  If the percentage of free PSA is higher than 25, then the elevated PSA is more likely to be caused by BPH, benign enlargement of the prostate.  If it’s lower than 25 percent, this doesn’t automatically mean that there’s cancer, but it does raise the likelihood that cancer may be present.  The 4K and PHI tests are even more helpful than the free PSA test, because they also look for biomarkers of aggressive cancer, and put it all together into a score.

What if these things point to cancer?  Is the next step biopsy?  No, it’s prostate MRI.

I’ve written about that here, but basically, the result of prostate MRI is called a PI-RADS score, ranging from 1 to 5.  A PI-RADS score of 3 or higher is the trigger for a biopsy.

That biopsy should be an MRI fusion biopsy, where the MRI image is combined with transrectal ultrasound to give the doctor the best view of any suspicious areas that really need to be checked.  In the biopsy, 12-14 hollow-core needles are used to get samples, or cores, of tissue.  Note:  a biopsy is not perfect; each needle only samples 1/10,000^th of the prostate!  In the book I’ve said it’s like looking with a needle in a haystack.  That’s why the second-line tests can help paint a more complete picture of what’s going on in the prostate.

            There are two ways to have the biopsy done:  through the rectum (transrectal) and through the perineum, the area of skin between the rectum and the scrotum.  If you think of the prostate as about the size of a golf ball, the transrectal approach basically goes from south to north.  The transperineal approach goes from east to west, and it does a much better job of finding out-of-the-way cancer.  I’ve written about that here.  Not only is it more effective:  there is zero risk of infection.  No need for antibiotics!  It’s also better for diabetic men, who are at higher risk of getting an infection.  The transrectal approach, because it goes through the rectum, involves antibiotics.  There’s no getting around it; the rectum is chock full of bacteria.  Transperineal is the better way to go.

Since this series is about screening and detecting cancer, I’m going to leave it here and not get into treatment.  That is covered throughout this website, and if there’s interest, will be the subject of another series.  Very briefly, if cancer is found, you will be given a Gleason score, or Gleason grade group.  The cancer can range from very low, low, and favorable intermediate risk – which may not ever need treatment – to unfavorable intermediate, high, and very high risk.  You will also be given a clinical stage, which is the estimate of how much cancer there is – whether it is confined to the prostate (the most common scenario in the U.S. today because of screening); whether it has spread locally but does not appear to be present at distant sites (seen with imaging); or rarely, less than 10 percent of the time, whether the cancer has spread to either the lymph nodes or bone.  Whatever the finding, don’t become discouraged!  There is more hope now than ever before.

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.  Note: I am an Amazon affiliate, so if you do click the link and buy a book, I will theoretically make a small amount of money.  

© Janet Farrar Worthington