When we take any test, it is preferable to get a definite answer: “yes, you have the cancer” or “no, you don’t”. Unfortunately the PSA test is not that good. At best, it is an indicator of the probability or risk that you have prostate cancer. This can be very helpful, because it guides the decision about whether you should have further tests. However it does mean that the interpretation of PSA levels is not necessarily straight forward.

What conditions other than cancer cause the PSA level to rise?

The prostate typically enlarges as men grow older, and because small amounts of PSA are produced by the healthy prostate, its blood level tends to rise. Benign prostate enlargement (a condition which causes urinary symptoms such as poor flow, getting up at night), is a common non-cancer condition causing PSA levels to rise. For this reason, age-based thresholds, shown in Table 1, can be used to decide if a test result is abnormal. The percentage Free to Total PSA (described below) also gives an indication whether raised PSA is due to benign enlargement.

A temporary rise in the PSA can be caused by a number of conditions ¹. Urinary infection, prostatitis (inflammation of the prostate), or a biopsy of the prostate can cause large rises while small rises can be caused by ejaculation and even bicycle riding. Because of these non-cancer causes of PSA rises, it is not surprising that if you have an abnormally high test result, it may not be due to prostate cancer. The chance that you have prostate cancer is only about one in three.

Note: These levels are used only as a guide. It is possible to have prostate cancer and have a PSA level in the normal range, although this is uncommon.

If, in addition to the PSA test, you have a rectal examination, and it also is abnormal, your chances of having prostate cancer are higher, (one in two).

Other ways of measuring PSA have been developed in an effort to make the test more specific for prostate cancer. One of these is called the “Free to Total” PSA. This is a ratio, expressed as a percent. Much of the PSA in the blood is bound to protein, including that produced by cancer cells. But men with benign prostate enlargement have higher levels of free (unbound) PSA and so a higher Free to Total ratio. If the total PSA level is abnormal, the Free to Total PSA ratio will give an idea of whether the rise is due to benign disease or cancer. Cancer is more likely if the Free to Total percentage is below 10% ². This test is available and widely used throughout Australia.

What is a normal PSA level?

Most authorities agree that if you have a PSA greater than 4 ng/ml, you should have further investigations. Some suggest that if your PSA is greater than the ‘normal for age’ range shown in Table 1, or if it is rising rapidly, it should be investigated.

Depending on your age and family history, your doctor may then refer you directly to a Urologist, or may repeat the test before referring you for further investigation.

If cancer is present, the level of PSA in the blood rises as the tumour grows. This means that small rises in PSA are found in association with small tumours which may be still confined to the prostate gland (localised). PSA levels of 10ng/ml or less have the best chance of being localised ³. The PSA level and the cancerous characteristics of the tumour cells themselves (called “grade”) can indicate the risk that a tumour has grown beyond the prostate.

If cancer is present, the rate at which the PSA level increases over a series of tests (called PSA velocity) also gives information about the risk that cancer will recur after treatment.

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