What is PSA (Prostate Specific Antigen)?

Richard Beven-Thomas Urologists at USMDPCC
By: Dr. Richard Bevan-Thomas

January 23, 2013

Prostate Specific Antigen (PSA) is an enzyme produced by the glandular cells of the prostate. A PSA test measures the level of this enzyme in the bloodstream. A rising PSA level can be an indicator of prostate cancer.

PSA is a protein made in the prostate gland in ductal cells. These cells make some of the semen that comes out of the penis during sexual climax (orgasm). PSA helps to keep the semen in liquid form and also help the sperm penetrate the egg for fertility. Typically only a small amount of PSA is present in the bloodstream. However, sometimes an abnormality is present in the prostate, which creates a vent for the PSA to pass directly into the bloodstream. Cancer cells can cause such an abnormality. When a PSA test reveals a high level of the enzyme in the bloodstream, it can indicate prostate problems, including cancer.

The PSA Test

The FDA approved the use of the PSA test to monitor patients with prostate cancer in 1986. The use of this test was further expanded in 1994 to be used along with the digital rectal exam to detect patients at risk of having prostate cancer. The use of the PSA test has been shown to save lives. A European study has shown cancer deaths were reduced by 40 percent among men who were screened with the PSA test as compared with those who were not tested. However, the PSA test has not been without controversy. A recent review by the USPSTF has stated that healthy men under the age of 75 should not receive a PSA test and that men should not routinely have the screening performed. The urological community, however, does not universally accept this recommendation.

The Challenge

The challenge for physicians lies in the fact that a PSA reading does not offer an absolute, concrete number to indicate cancer. Sometimes a rising PSA level is indicative of prostate enlargement, infection or inflammation. A rising level of the enzyme may indicate that a biopsy might be needed, however it may also necessitate close monitoring of the PSA to ensure that this is indeed elevated without a know cause. Although there is no true cutoff for a normal PSA, a PSA greater than 2.5 should raise suspicion about a possible focus of cancer. Just as concerning is the rise in PSA over time. If a man has a PSA below 2.5 and a rise in his PSA of >0.35 per year or a PSA >2.5 and a rise in his PSA of 0.75 per year, this also should raise the concern of possible cancer. The UPSTF recommendation came about because of the risks associated with the prostate biopsy along with the inherent risks associated with treating prostate cancer. Current options for treatment include surgery (robotic prostatectomy), radiation and cryoablation. Not all men, however, require treatment and for men with lower grade (Gleason 6 score or less) and lower volume cancer, active surveillance is a potential option. Active Surveillance is a protocol to monitor the growth of low grade cancers to delay treatment (sometimes permanently) until there is evidence of further growth of the cancer or evidence that higher grade cancer has developed. This routinely entails serial PSA readings along with follow up biopsies and imaging studies of the prostate. The UPSTF recommendation against PSA screening partially rests on their assumption than any man with an elevated PSA will be rushed towards radical treatment. In the Urology community and at USMD Prostate Cancer Center, this is simply not the case. Through our Active Surveillance program and experience evaluating PSA results and advanced biopsy techniques, we are now more confident that we can follow selected patients and delay treatment under close observation. Prostate Cancer is a silent disease with few to no symptoms in the early stages. Prostate Cancer continues to take the lives of roughly 30,000 men each year and unless we detect which patients are at risk, this number will almost invariably rise in the coming years.

USMD Prostate Cancer Center Doctors recommend yearly testing after the age of 40, so a track record of PSA levels can be established. This, in conjunction with family history, age, race, digital rectal exam, and any presenting symptoms, can help establish the true need for a biopsy.

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