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DEAR MAYO CLINIC: I recently had a physical, which included a check of my PSA level. The doctor said my PSA level is elevated, as it has been in the past. I have undergone several biopsies that have not shown cancer. Do I need to continue with biopsies every year?
ANSWER: It may not be necessary for you to continue with annual prostate biopsies. But that depends in part on the overall level and rate of change of your prostate-specific antigen, or PSA, over time. Along with information about your PSA, your health care provider can use several other tools to determine if you need additional biopsies or if you can be monitored safely without further biopsies.
The PSA test measures the amount of prostate-specific antigen in your blood. PSA is a protein produced by both cancerous and noncancerous tissue in the prostate — a small gland that sits below a man's bladder.
When PSA is found to be above normal levels, a prostate biopsy may be recommended to check for cancer. Biopsies involve using a needle to collect several tissue samples from the prostate gland. Then the samples are examined in a lab to see if they contain cancer.
Although the PSA test is used primarily to screen for prostate cancer, other medical conditions can cause PSA levels to rise, as well. One of the most common is benign prostatic hyperplasia, or BPH. Basically, this condition is enlargement of the prostate gland that doesn't involve cancer. Benign prostatic hyperplasia is common as men get older.
To see if benign prostatic hyperplasia could be causing your elevated PSA, talk with your health care provider about getting an imaging exam, such as an ultrasound or an MRI, to assess the size of your prostate gland and look for suspicious areas. Then the PSA can be viewed in the context of the overall size of the prostate, a concept known as PSA density.
When the prostate gland is significantly enlarged in men with higher-than-normal PSA, it is often the case that benign prostatic hyperplasia is the source of the elevation. That's particularly true for men in that group who have had multiple negative biopsies for prostate cancer.
In addition to imaging, several in-depth blood tests have been shown to be useful for evaluating prostate cancer risk in men who have elevated PSA. The tests include the prostate health index, or PHI; free PSA test; and 4K score. These blood tests look at other proteins, in addition to PSA, and use mathematical algorithms to predict the likelihood of more aggressive forms of prostate cancer being present.
If it is determined that a man has an enlarged prostate and tests indicate that the risk for cancer is not high, it makes an elevated PSA less of an immediate concern. That allows the primary focus to shift from cancer detection to managing bothersome urinary symptoms that often accompany benign prostatic hyperplasia, such as frequent or urgent need to urinate, increased urination frequency at night, weak urine stream, difficulty starting urination or inability to completely empty the bladder. Treatment for these symptoms is available, including medication and, in some cases, surgery.
At this point, though, it's important that you be evaluated further to better understand your situation and guide your care going forward. Although a prostate biopsy can be a valuable tool for detecting prostate cancer in its early stages, having unnecessary biopsies can needlessly expose you to health risks, raise health care costs, and cause unwarranted worry and anxiety. Planning for future tests and procedures in a way that will avoid unnecessary prostate biopsies is in your best interest. — Dr. Chandler Dora, Urology, Mayo Clinic, Jacksonville, Florida
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