Help interpreting PSA test

First let me say, I have nothing diagnosed just in limbo waiting on follow up(s) I did have a question about interpreting recent labs. Google isn’t always your friend. There is so much contradicting information on the web and from what I’ve read on here so far I feel I’ll get a better answer.

I’m 55, avg weight, family history of PC.

Jun 14 - 5.08
Jun 24 - 4.45 (retest) sent for referral

No lumps or other noted abnormalities noted during DRE but ordered a further PSA with free/total. Here’s where I’m confused

Oct 14 - 5.2
0.58 fPSA
11.2% fPSA (Alt method)

How does the fPSA actually relate to the total. Given the above what would typically occur next? Monitor/retest, biopsy?

Post Edited (Swokie) : 10/27/2021 1:27:51 PM (GMT-6)

Thanks for your reply. No, urologist didn’t say to much about the DRE at the time, only that with history is why he ordered further bloodwork before proceeding. I got the results early. Won’t see him till mid Nov, hence my overthinking of the results. He has said he doesn’t like biopsies unless truly warranted, so should this flag prompt that discussion with him I will suggest an alternative like you’ve mentioned first! Given what I know from my Dad’s experience I’m quite hesitant as I believe most would be/are. Knowing full well there may be a point when that’s the prudent option, just hoping I can delay.

Hi Swokie and welcome! Were you told you had an enlarged prostate (BPH)? Was the 5.08 your first PSA test? With a family history, I expect PSA would have started much earlier.

I would want either a biopsy or an mpMRI (to evaluate and then decide about a biopsy). Further investigation in my book is a win-win. If everything is good, you have peace of mind and a baseline against which to measure any future changes, e.g. PSA. If you have a small amount of indolent (Gleason 6) cancer you can be monitored on active surveillance. Finally, if you do have clinically significant prostate cancer, you have gained the biggest weapon in the arsenal: early detection and treatment.

Djin

BPH (benign prostate hypertrophy) is just medspeak for an enlarged prostate. By itself, it's just the excess growth of healthy tissue, but it can cause difficulty urinating and can raise the PSA. This PSA rise can mask a concurrent rise in PSA cause by prostate cancer. The fact that your doc wanted a biopsy "then" says it all, at least to me.

You don't want to delay investigation a significant amount of time only to find out that you have serious cancer. You'll be asking yourself "what if I had acted sooner? Would it have made a difference?" Most uros want to rule out PCa in biopsy-naive men.

I had a 25-year history of gradually increasing PSA from an enlarged prostate. I had periodic biopsies (all negative) whenever the rise in my PSA was a bit higher than what my uro at the time thought could be attributed to the BPH alone. I never questioned their judgement. Many years and nine biopsies later, they found serious high-grade prostate cancer. I had surgery (about 4.5 years ago). I attribute the success of the surgery (so far no further treatment necessary) entirely to very early diagnosis and treatment.

In the great majority of cases (and every one of mine) a prostate biopsy is No Big Deal.

All the best,

Djin

Hello and welcome. You actually sound a lot like me. I started having PSA tests at 45, once a year--at my Dad's suggestion as he was well into his own PC journey at the time. Mine were essentially zero's for several years, then I started seeing increases at 52, with annual doublings every year. I was diagnosed and treated at 56, and was G7 (3+4) which means low intermediate risk.

My final PSA before surgery was 6.0, and my biopsy as I recall showed 3 cores positive out of 12 on a blind TRUS biopsy.

My uro is very diligent about ruling out non-cancerous reasons for higher than normal PSA before subjecting someone to a biopsy, absent a suspicious DRE or very high PSA. He is a strong user of Avodart (he was a principal investigator in three major trials, and written research papers regarding the uses of Avodart). Often he will use a course of 6-9 months and monitor PSA and DRE monthly. Typically this will reduce the prostate size and hence PSA by about 35%. Then if the PSA starts going up and/or he feels something, then PCa is usually the reason. At that time he goes to the MRI and, if warranted, the biopsy. He further says that using the Avodart improves the MRI reading and biopsy by condensing the target and improves the DRE sensitivity for better accuracy. With average positive biopsies still at only about 50%, many are premature and unnecessary. He reports that his average positive is in the 85-90% range.

Skokie, you might add this to the discussion list for your November uro visit.

I would not wait much longer before further diagnostic testing given that (1) you put off your doc on this some years ago. A recent study confirmed previous studies concluding that a tumor burden (amount of cancer in the entire prostate) of above 8% statistically increases the rick of recurrence after primary treatment by about 70%. Prostate cancer grows with time. That is coupled with (2) your % free PSA, (3) family history, and (4) increasing PSA. You said "just hoping I can delay," however, IMO the ostrich approach could be delaying good news or working against your best interests if you do need treatment.

Djin

Swokie, nothing is going to change significantly between now and your appointment.

My point and philosophy is this: say your chance of currently having clinically significant disease is X%. Ask your doc for an estimate of that number. That number, at least for me, would have to be very low for me to say thanks, but those odds are good and I don't want to find out. If that chance is 5, 15, or 25%, it doesn't change things as I see it--I would want to know.

Djin

I would suggest that you request an MRI to find any suspicious areas. Also, an MRI will note your prostate volume, which can be used to calculate your PSA Density. Johns Hopkins, whose AS group I have participated in since 2009, considers PSA Density to be more significant than total PSA or free PSA in determining if a biopsy is warranted.

Hi ShawsUnprostatedMan.

Can Tumour Volume Percentage in Radical Prostatectomy Predict Cancer Biochemical Recurrence? Determining a Cut-off Point and Composite Risk Factors Approach (2021, Full Text)

"Abstract
Background
Incidence of biochemical recurrence (BCR) after radical prostatectomy is relatively high and overall survival can be poor. Debate exists whether tumour volume predicts BCR and when treatments should be administered. In this study, we aimed to i) assess the impact of tumour volume percentage (TVP) as a predictor for BCR, ii) determine TVP cut-off point for BCR and iii) evaluate single and composite predictors of BCR.

Methods
From March 2000 to December 2013, 1777 patients underwent laparoscopic radical prostatectomy for localized prostate cancer. None received neoadjuvant or adjuvant therapy. One hundred and forty-six patients experienced BCR (range 3 months-10 years). Using D’Amico classification, 146 matched controls without BCR were compared. Liu cut-point analysis was used to identify TVP with optimal sensitivity and specificity. Single and composite BCR risk predictors were analyzed using Cox hazards regression in cases and controls.

Results
Median TVP was 10% (range 1–90%). Most of BCR peaked after 3 years of follow-up. TVP ≥8% was an independent predictor of BCR with HR 1.6 (p= 0.001, 95% CI= 1.11–2.48). TVP of 8% was associated with the highest accuracy: sensitivity 74% and specificity 53% (ROC curve= 0.7). At TVP ≥8%, pathological stage pT3 was associated with 1.7-fold higher risk of BCR compared to T2. Lymph node invasion was associated with 1.4-fold higher risk of BCR compared to no invasion. Combining TVP ≥8%, pT3 and lymph node invasion, HR jumped to 3.73 (p< 0.001, 95% CI= 2.27–6.14), whereas combining TVP ≥8%, positive surgical margin and lymph node invasion, HR was 2.68 (p= 001, 95% CI= 1.50–4.77).

Conclusion
TVP can be used as an independent predictor of BCR after radical prostatectomy for prostate cancer. TVP cut-point of ≥8% allows the best discrimination. TVP should be considered in combination with other clinico-pathological factors to improve prediction of long-term oncological outcomes and to stratify BCR risk."

(See Full Text)

Djin