All you need to know

What is PSA?

PSA stands for Prostate Specific Antigen.
It is a protein made by the prostate gland, which naturally leaks out into the bloodstream. From puberty, a man’s prostate gland will begin to enlarge and produce an increase in PSA, therefore ‘normal’ levels increase with age.

So a blood test can be used to measure the level of prostate activity. The prostate’s function is to produce some of the fluid that helps carry sperm when men ejaculate.

How is it measured?

The level of PSA in the blood is measured by a blood test, which can be analysed at most NHS or private laboratories. Only a small amount of blood is taken from a vein in the arm by a trained phlebotomist, so you shouldn’t feel any significant after-effects. This is called a venous blood test.

What does it tell me?

The PSA test is NOT a test to diagnose prostate cancer. A high reading can sometimes indicate abnormalities such as –

  • a normal enlargement of the prostate;

  • a urinary infection;

  • inflammation of the gland (prostatitis);

  • urinary retention;

  • any recent prostate procedure such as a biopsy or TURP operation;

  • or it could be prostate cancer, especially if the PSA reading is very high.

The rate at which the PSA level increases over time may give the doctor a better indication of a problem with the prostate. Therefore, monitoring the PSA level at regularly intervals, is a more reliable indicator than a one-off test. Evidence from a European Trial, suggests PSA screening could reduce prostate cancer related mortality by 21%.

What are the advantages and disadvantages of the test?

Advantages:

  • The PSA test is currently the best method of identifying increased risk of prostate cancer in men with or without symptoms.

  • It can lead to an early indication of cancer at a potentially curable stage, before symptoms appear.

  • It may reassure you If the result Is normal.

However:

  • Typically, three out of four men with a raised PSA do not have cancer. Called a ‘false positive’ result.

  • A definitive diagnosis requires an MRI scan and possibly a biopsy of the prostate.

  • A raised PSA may therefore lead to further tests, which may prove to be unnecessary.

  • In around 15% of men who have a normal PSA, cancer is present, as some rare forms of prostate cancer do not raise the PSA level. This is called a ‘false negative’ result.

Your rights

All men over the age of 50 are entitled to discuss the option of having a free PSA test with their GP as part of a scheme called the Prostate Cancer Risk Management Programme (PCRMP, Public Health England, Mar 2016).

The PCRMP is there to help GPs give clear and balanced information to men without symptoms who ask about PSA testing. Your GP will be expected to discuss with you the benefits, limitations, and risks of the PSA test to help you decide whether or not to have it. Under the guidelines of the PCRMP, after such a discussion, it is the right of any well man over 50 years to decide for himself whether to have the test or not free on the NHS.

GPs should use their clinical judgement to manage men who have symptoms and those aged under 50 who are considered to have a high risk for prostate cancer.

Knowing your result

It is important that you know the actual result. You are advised to keep a record of the figures from each test in order to check for any abnormal rise. PSA rises naturally with age, although expert opinions vary, there is no clear consensus regarding the optimal PSA threshold for recommending referral for further investigations. The PCRMP issued by Public Health England, recommends PSA levels greater than 3.0 ng/ml for men in the 50-69 age group should be referred. There are no recommended referral levels for men 70 and over or for men under the age of 50. Your GP and/or urologist will advise you on this.

The following are PSA levels that PCaSO and some NHS Hospitals are currently using,

Age related PSA normal scores

Under 50 Less than 2.0 ng/ml*

50 to 59 Less than 3.0 ng/ml

60 to 69 Less than 4.0 ng/ml

70 and over Less than 5.0 ng/ml

A raised level of PSA should prompt further investigation by your GP, who may wish to give you a Digital Rectal Examination (DRE for short) which may provide further information. If there is cause for concern, you will be referred to a urologist at your local hospital, who may decide to give you further tests to identify the cause.

How often should you have a test?

International guidelines and recommendations on prostate cancer screening:

  • Start testing at age 45 or 40 if there is known risk (see below).

  • If PSA is less than 1.0 ng/ml then return for testing every 6 to 10 years

  • If PSA is between 1.0 and 3.0 ng/ml then return for testing every 2 to 4 years

As a general rule, the closer your result is to the guideline for your age, the more regularly you should be tested.

Can I have the test at any time?

Under the NHS it is only recommended for men over 50. You should avoid any vigorous exercise (particularly cycling) or ejaculation (low risk), for 48 hours before the test as both, in some men, can cause mild elevation. Conversely, if a man is taking medication for an enlarged prostate (finasteride/dutasteride/combodart), the PSA reading will be half its true level. The implication of this is that whilst your recorded PSA result is within “normal” levels, when doubled, it may indicate a raised level requiring further investigation.

Risk

If you are at special risk (have a family history of prostate or breast cancer, faulty BRCA gene, or are African or Afro-Caribbean), we suggest you should start having a PSA test in your early 40s as you are potentially 2 to 3 times more at risk of developing prostate cancer.

Every year in the UK over 47,000 men are diagnosed with prostate cancer (130 every day). It is the most common cancer in men over the age of 55 years and an estimated 1 in 8 men will develop the disease in their lifetime, with 1 in 25 men dying of the disease. 1 in 2 men, however, will have a prostate problem in their lifetime, usually caused by an enlarged benign prostate.

If cancer is diagnosed

Don’t panic! Many cancers are low grade and may never cause problems. Such cancers are just regularly monitored – called Active Surveillance. If it is found to be more serious, then treatment such as surgery or radiotherapy is advised. Your cancer may well be cured if it is confined to the prostate.

Have you some concerns about the test?

The main concerns of some medical practitioners are – “it is inaccurate” and “it risks over-treatment”

However, the PSA test alone is never used to diagnose but simply to help identify men with a prostate health problem or risk of cancer.

Those found to have low risk disease are put on Active Surveillance. Only those found to have a more aggressive cancer are offered treatment.

Yes, some treatments may have implications with sexual and/or bladder function, but many men may prefer this to being one of the 11,800 men who die in the UK each year of the disease.

Greater awareness and an effective screening programme would likely reduce the number of men diagnosed in the UK with locally advanced or advanced disease, currently 40% of total cases.

Conclusions

The death rate from prostate cancer in the UK is higher than the average for EU countries. It is thought that lack of awareness by men of the risks of prostate cancer is an important reason for this distressing situation. We recommend:

> Don’t be put off having a PSA test, if necessary quote the PCRMP.

> Always “know the score” and record your result.

> A single random PSA test is of minimal benefit, The biggest gains (40 to 50% fall in mortality in Europe) are achieved by having repeated regular PSA tests starting in your 40s or early 50s.

Until recently there was much concern that PSA testing could lead to over treatment of indolent cancers, reducing patients’ quality of life. Improved diagnostic techniques including multi-parametric MRI scanning has reduced the need for invasive biopsies and enabled use of Active Surveillance to monitor less significant prostate cancers. The “over-treatment” rate in the UK is now down to 4% and still falling.

Here to help

PCaSO Prostate Cancer Support Organisation is your point of contact for advice and support if you live in Sussex, Hampshire or Dorset. We are an entirely volunteer patient-run charity with around 1000 members.

Ask for our acclaimed Prostate Cancer Information Booklet “Knowledge Empowers” if you need further information.

Website: www.pcaso.org Email: info@pcaso.org

National helpline number: 0800 035 5302

Postal address: PO Box 66, Emsworth, Hants PO10 7ZP

Our Medical Advisers:

Prof. Christopher G. Eden, MS, FRCS (Urol.)
(Royal Surrey County Hospital)

Dr Chris Parker, BA, MD, MRCP, FRCR
(Royal Marsden Hospital and Institute of Cancer Research)

Dr Angus Robinson, MBBS, MRCP, FRCR
(Royal Sussex County Hospital)

For information about PSA test events being held in our region:

Sussex – Roger Bacon 01903 775783

Hampshire – Peter Weir 01489 892168

or check the website: www.pcaso.org

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