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  • Michael Misialek, MD

So Your PSA is Elevated, What Next?


You just received your lab results and found out that your PSA is elevated. You have heard how important it is to screen for prostate cancer. You asked your doctor for the test and now what?

Prostate specific antigen (PSA) is a protein secreted by the prostate. It is elevated in 80% of prostate cancers but also can be seen due to benign causes. These include common conditions such as benign prostatic hyperplasia (BPH, prostate enlargement) and inflammation. An elevated PSA is a red flag and an indication to undergo further testing to determine the cause.

Often times the level will be repeated, along with a referral to a urologist. Workup includes a complete physical exam including a digital rectal exam to evaluate the prostate. This was most likely done when your PSA was checked. Depending on the PSA level and other risk factors, an imaging study, such as an ultrasound, and biopsy may be performed.

New diagnostic techniques are available which can yield additional information and can help in the decision of whether to perform a tissue biopsy. The Prostate Health Index (PHI) test is a combination of three forms of the PSA protein. The results are used to provide a probability of cancer. The 4K score is a blood test measuring 4 different prostate related proteins that provides a percent risk score of having an aggressive prostate cancer. Another test is the Prostate Cancer Gene 3 test (PCA3) which is a gene based test carried out on urine. The higher the level, the more likely the chance cancer is present.

One of the newest and most promising techniques for further evaluating the prostate is the UroNav MR/Ultrasound Fusion Biopsy System. Fusion biopsy is a more effective method for detecting and diagnosing high risk and aggressive prostate cancers and results in less false negatives. MRI biopsy is likely to become an important tool in the evaluation of prostate cancer since the traditional random biopsy may miss tumor or in 30% of the time, underestimate the Gleason score of tumor.

Then what?

If a biopsy is done, a pathologist will evaluate the biopsy under a microscope and make a diagnosis. The most important feature to know about the cancer is the Gleason score. This is a grading system that a pathologist assigns to the tumor. A higher score suggest a more aggressive tumor. Other features that are assessed for include: the amount of tumor, the percentage of tumor in each biopsy sample, tumor length and whether tumor invades small nerves of the prostate. All of these will be recorded in the pathology report. Get a copy of your report.

Other important diagnoses that might be encountered are:

Atypical small acinar proliferation (ASAP) – This is an area that has microscopic finings equivocal for cancer, i.e. suggestive but not diagnostic. It is predictive of cancer and often an indication for repeat biopsy.

Prostatic intraepithelial neoplasia (PIN) – This is another finding that has microscopic features worrisome for cancer. It carries a 20% risk of cancer on repeat biopsy. Like ASAP, it warrants close follow up.

Your pathologist is an important member of your care team. Ask about the pathologist involved in your case. Request a copy of your pathology report. Understand the report. Ask questions.

#pathologycancerslidesspecimens #prostatecancer #psa #cancer #cancerscreening

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