PSA value and prostate cancer: what an elevated result means and when testing is worthwhile

What is PSA and where is the prostate located?

The prostate is a walnut-sized gland that only men have, located below the bladder and surrounding the urethra. The prostate produces part of the seminal fluid and also produces PSA, a protein that helps keep the semen fluid after ejaculation.

A small amount of this PSA leaks from the prostate into your blood, where it can be measured. In a healthy prostate, this is a small, stable amount. If the prostate tissue becomes damaged, inflamed, or begins to grow abnormally, more PSA leaks into the blood and your value rises.

What does an elevated PSA value mean?

About 1 in 10 men have an elevated PSA value at some point, and that by no means always means cancer. The main causes are:

Benign prostatic hyperplasia (BPH). As men age, the prostate naturally grows slightly in many men, without this being malignant. This is the most common cause of an elevated PSA.

Prostatitis (inflammation of the prostate). An infection or inflammation can temporarily significantly increase the PSA value, often accompanied by symptoms such as pain or a burning sensation during urination.

Recent physical irritation of the prostate. Intensive cycling, ejaculation, or a prostate examination shortly before the test can cause the value to rise temporarily.

Age. The prostate gradually grows with age, causing the PSA value to be naturally somewhat higher in older men without anything being wrong.

Prostate cancer. Prostate cancer can also increase the PSA value, usually more gradually than inflammation. This is the reason why the test exists, but it is certainly not the only or most likely explanation.

An elevated result is therefore a signal to investigate further, not a diagnosis in itself.

Enlarged prostate (BPH): is it dangerous?

Benign prostate enlargement, also known as BPH (benign prostatic hyperplasia), is the most common cause of both elevated PSA and urinary problems in older men. The prostate then grows gradually and presses against the urethra. Common symptoms include a weaker stream, needing to urinate more frequently (especially at night), difficulty getting started, and the feeling that your bladder is not completely empty.

BPH is benign: it is not a form of cancer and does not develop into it. However, the symptoms can be bothersome and worsen over time. For mild symptoms, watchful waiting and lifestyle advice are often sufficient, such as reducing caffeine and alcohol in the evening and taking the time to urinate properly (urination advice). For bothersome symptoms, a doctor may prescribe medication that relaxes the muscles around the prostate or causes the prostate to shrink. For severe symptoms that do not respond to medication, surgery is an option, for example a TURP, in which part of the prostate is removed through the urethra. Please note: certain BPH medication (5-alpha-reductase inhibitors, such as finasteride) lowers the PSA value by approximately half over time. If you use this type of medication, always tell your doctor before your PSA result is assessed; otherwise, your value will appear more favorable than it actually is.

When is a PSA test useful?

The Dutch GP guideline is cautious on this: PSA is not actively offered to men without symptoms, because the test is uncertain enough that it could just as easily cause unnecessary examinations and anxiety as it could save lives. It is a decision you make together with your GP, not a standard part of a check-up.

Considering a test is useful in these situations:

• With symptoms that may be consistent with the prostate, such as difficulty urinating, a weaker stream, needing to urinate more often at night, or blood in the urine.
• With a strong family history, especially if your father or brother was diagnosed at a young age.
• With a known hereditary predisposition, such as carrying the BRCA2 gene mutation. For this group, biennial monitoring of the PSA value is recommended.

For men with a limited life expectancy, typically older than 75 years or younger with serious other health problems, a PSA test is actually discouraged. In that situation, a potential slow-growing tumor would often no longer affect lifespan or quality of life, while the test can lead to unnecessary investigations.

A PSA test alone without a medical history and physical examination (rectal examination) is not useful. PSA is part of the complete picture.

What are normal PSA values?

The Dutch guideline uses a fixed threshold, regardless of age: a PSA value below 3 ng/ml means that the risk of prostate cancer is low. With a value of 3 ng/ml or higher, and without indications of inflammation, follow-up investigation is customary.

Note: a higher value is not proof of cancer, and a low value does not completely rule it out. PSA is a signal to investigate further, not a definitive result. A rapid rise in the value over time, even within what appears to be a normal result in itself, can also be a reason for a doctor to conduct further research.

You may also occasionally come across a table online with age-dependent PSA thresholds, for example 2.5 ng/ml up to age 50, rising to 6.5 ng/ml after age 70. These age-dependent values ​​have never proven to be sufficiently substantiated and are no longer used in the current Dutch guideline, which applies the same limit of 3 ng/ml for every age.

What can you do yourself?

• Know the symptoms. Difficulty urinating, a weaker stream, urinating more often at night, or blood in the urine are reasons to talk to your GP, regardless of your age.
• Prepare well for a test. Avoid intensive cycling and ejaculation in the 48 hours before a PSA test; this can temporarily affect the result.
• Know your family history. If you know of prostate cancer in your father, brother, or son, discuss this with your GP, even without symptoms.
• Consult before you test. Because the test is not perfect, it is wise to discuss the pros and cons with your GP beforehand, rather than just skipping it. do.
• In case of an elevated result: do not panic immediately. A follow-up test, or additional examination such as an MRI, often provides more clarity quickly.

Conclusion

An elevated PSA value is more often the result of benign prostate enlargement or inflammation than of cancer, but it always warrants further explanation by a doctor. Because the test is not perfect, the Dutch guideline does not offer it as standard to men without symptoms: it is a joint decision between you and your GP, in which symptoms, family history, and age all weigh. If you are in doubt, discuss the pros and cons with your GP before having a test done.