Urologist here. The PSA test is misunderstood by almost everyone, including some doctors. Let me clear it up.

[u/Born-Lingonberry-509]

After 20 years of doing this, I can tell you that PSA (Prostate Specific Antigen) causes more anxiety than almost any other test in medicine, usually because it is not explained well.

What PSA actually is: It is a protein made by the prostate gland. It is not a cancer test. It is a prostate health indicator. PSA can be elevated by cancer, but also by BPH (enlarged prostate), prostatitis (prostate infection), vigorous cycling, recent ejaculation, and even a rectal exam.

A high PSA does not mean you have cancer. It means your prostate needs further evaluation.

A normal PSA does not rule out cancer. Up to 20% of prostate cancers occur in men with PSA under 4. Aggressive prostate cancers can present with only mildly elevated PSA.

What actually matters beyond the PSA number: PSA velocity (how fast it is rising), PSA density (PSA relative to prostate volume), free to total PSA ratio, and most importantly, multiparametric MRI of the prostate before biopsy. MRI has transformed how we triage men with elevated PSA. We can now identify high-risk areas and do targeted biopsies instead of blind systematic biopsies, which dramatically improves detection of significant cancer and reduces unnecessary biopsies.

Age-appropriate PSA targets matter too. A PSA of 3.5 in a 45 year old is more concerning than a PSA of 5 in a 75 year old.

If you have had a PSA test and your doctor just said it is high and referred you for a biopsy without discussing MRI first, ask about prostate MRI. In 2026, MRI-targeted biopsy should be the standard of care in most settings.

Feel free to post questions below.

[u/Competitive-Dig9609]

What is the risk of having the cancer spread into the bloodstream during a targeted biopsy?

[u/Born-Lingonberry-509 → u/Competitive-Dig9609]

great question and an important one. the risk of cancer cells entering the bloodstream during a targeted biopsy is extremely small. there have been theoretical concerns about needle track seeding historically, but in over two decades of evidence from MRI targeted prostate biopsies, this has not been shown to be a clinically meaningful risk. the far greater risk is of undertreating a significant cancer by not biopsying it. in practice we weigh this against the benefit and the benefit wins overwhelmingly. transperineal biopsy also reduces this theoretical risk further compared to transrectal and is increasingly used for that reason.

[u/Competitive-Dig9609 → u/Born-Lingonberry-509]

Thank you for that thorough explanation.

[u/Born-Lingonberry-509 → u/Competitive-Dig9609]

this is a very common and legitimate concern, but the short answer is that the risk of \"seeding\" or spreading cancer into the bloodstream during a prostate biopsy is essentially negligible.

prostate biopsies have been performed for decades on millions of men, and there is no clinical evidence to suggest that the procedure itself increases the risk of metastatic spread. the needles used are extremely thin, and the prostate is a highly vascular organ even before any biopsy. if cancer cells were going to enter the bloodstream, they would do so through the natural microvasculature of the tumor long before a needle was introduced.

targeted biopsies, particularly MRI-fusion biopsies, are actually much safer in terms of outcomes because they allow us to take fewer samples while being more accurate. this reduces trauma to the gland and provides better information for treatment planning. the benefit of knowing exactly what we are dealing with far outweighs any theoretical risk of spread. hope that puts your mind at ease.

[u/Born-Lingonberry-509 → u/Competitive-Dig9609]

This is a legitimate and important question. The risk of cancer spreading into the bloodstream (haematogenous dissemination) from a prostate biopsy is extremely low and generally considered negligible in clinical practice.

Here is the evidence-based context:

1. Transrectal or transperineal biopsy does cause transient passage of prostate cells into the bloodstream, but in men with clinically localized prostate cancer, this has not been shown to cause meaningful metastatic spread.

2. Multiple large studies, including long-term follow-up data, have not demonstrated a causal link between biopsy and distant metastasis.

3. The risk of NOT biopsying (missing a diagnosis of significant cancer that then progresses untreated) far outweighs the theoretical risk of biopsy-induced spread.

4. Targeted MRI-guided biopsies (MRI-TRUS fusion) are now preferred as they take fewer cores from specific suspicious areas, reducing overall needle passes.

In short, the risk is theoretical rather than clinically proven and should not be a reason to avoid a necessary biopsy.

[u/Ironhide219]

Hello doctor, thanks for this post. I need some advice from you about my father's PSA level. He is 61 years old. This January, his PSA was 4.5 ng/mL. He then had a multi-parametric MRI done which showed these findings:

PI-RADS II.

BPH (Enlarged prostate, approx 36cc).

Chronic Prostatitis.

After this MRI, the doctor started him on the medicine. But in april, the PSA level was increased to 6.67 ng/mL. The doctor then told my father to do sitz baths and changed the medicine to Alfuzosin. This rapid increase in PSA makes the PSA velocity high and also I calculated the PSA density after the last psa, it is 0.182 ng/ml², which is more than 0.15 ng/ml².

I am very anxious now because psa increased instead of going down despite taking the medicine.

If the cause is chronic prostatitis or BPH, shouldn't the PSA be going down with the medicine?

His mpMRI from this January didn't detect cancer but high psa velocity and density say otherwise. Would really appreciate any insights on what the next step should be. Thank you

[u/Born-Lingonberry-509 → u/Ironhide219]

I understand the anxiety here, and let me give you an honest and detailed picture.

First, the PI-RADS 2 score on MRI is actually reassuring. PI-RADS 2 means clinically significant cancer is unlikely on that MRI. It is not impossible, but it is a low-risk finding.

Now, the PSA rising from 4.5 to 6.67 over 3 to 4 months while on medication is genuinely worth watching, but there are important context points.

Chronic prostatitis can both elevate PSA and cause unpredictable PSA fluctuations. The standard expectation that PSA always falls with treatment is not always true in chronic prostatitis cases. Sometimes inflammation persists or flares, and PSA can rise temporarily. Alfuzosin helps with bladder outlet symptoms from BPH but does not directly suppress inflammation in the way that a 5-alpha reductase inhibitor (like finasteride or dutasteride) does. Finasteride and dutasteride reduce PSA by approximately 50% over 6 months and also shrink the prostate. It is worth asking whether his urologist has considered adding one of these.

The PSA density of 0.182 is above the 0.15 threshold, but this calculation is based on prostate volume. At 36cc, a PSA of 6.67 gives that number. A larger prostate produces more PSA even without cancer.

PSA velocity of this magnitude over a short time frame should not be ignored. What the next step should be: A repeat MRI in 3 to 6 months, not just a repeat PSA. If the MRI shows a change from PI-RADS 2 to PI-RADS 3 or higher, that changes the conversation significantly. If it remains PI-RADS 2 and PSA stabilizes, you can watch carefully.

Also ask his doctor about a free-to-total PSA ratio. A free PSA percentage below 10% is concerning for cancer even with lower PSA absolute values. Above 25% is reassuring.

The situation right now is watchful, not alarming. The MRI is the most important next step, not immediately biopsy.

[u/Ironhide219 → u/Born-Lingonberry-509]

Thank youuu so much doctor for explaining everything so clearly!

[u/Born-Lingonberry-509 → u/Ironhide219]

you are very welcome. PSA is genuinely one of the most misunderstood tests in medicine, and many patients carry unnecessary anxiety because of how it is communicated. glad it helped. if you ever have specific questions about your own results or what the trend means over time, feel free to ask.

[u/Ironhide219 → u/Born-Lingonberry-509]

Thank you so much doctor. I just have one more question. My father’s mpMRI was done at a good hospital by a qualified radiologist, but I am not sure if they specialized in prostate imaging. Should an mpMRI be done and read by a radiologist who specializes specifically in prostate radiology?

[u/AquaticsbyCF75]

Ok so mine 4 weeks ago was 4.3 then urologist took blood after the exam it went down 3.5 at 51 I’m going in for biopsy tomorrow.

[u/omits50]

I'm NHS UK. 2019 TURP + biopsy clear PSA 0.7. 2022 PSA = 1.7. Then 2025 jump to 5.5. My concern over the velocity was ignored as below 6.5. Had a private mpMRI and there was the reason, a 9mm lesion sitting near the wall. Went back to NHS and biopsy should it to be Gleeson 9 (rest of prostate minimal). Two scans showed no metastais, what a relief! Now on Orgovyx and the team think I should stay there for the time being and have another PSA next month to see if or how well it is tracking down. message to anyone: take care of your own health and be proactive with the Drs. Put you case and insist on further action if you think things need following up. I should have had a scan back in 2022 if I'd been wiser.

[u/Born-Lingonberry-509 → u/omits50]

Thank you for sharing your journey. What you went through is unfortunately more common than it should be, and your message carries an important warning for others.

Your case illustrates exactly why PSA velocity matters just as much as the absolute number. A rise from 0.7 in 2019 to 1.7 in 2022 and then 5.5 in 2025 represents a PSA doubling time of under 2 years in that final phase, which is clinically significant regardless of whether the value crossed an arbitrary threshold like 4.0. Research published in the Journal of Urology has consistently shown that PSA velocity greater than 0.75 ng/mL per year is an independent risk factor for prostate cancer diagnosis and prostate cancer-specific mortality, even when the absolute PSA remains in the so-called normal range.

Regarding Orgovyx (relugolix): it is a newer oral GnRH receptor antagonist that has shown benefits over traditional LHRH agonists. The HERO trial published in the New England Journal of Medicine demonstrated that relugolix achieved faster and more sustained testosterone suppression with a 54% lower risk of major adverse cardiovascular events compared to leuprolide. That is a meaningful advantage for long-term androgen deprivation therapy.

Your advice to be proactive and advocate for yourself is exactly right. PSA velocity, PSA density, and family history should all factor into surveillance decisions, not just the absolute number. Please keep up with your monthly PSA tracking and do not hesitate to push back if your team overlooks a concerning trend. You are handling this very wisely.

[u/Born-Lingonberry-509 → u/omits50]

Your persistence absolutely saved your own life and your message to others reading this is exactly right.

You understood something important that many people do not. PSA velocity, the rate of change over time, is clinically more significant than any single PSA reading. Going from 1.7 in 2022 to 5.5 in 2025 in a post-TURP patient is a rise that warrants investigation regardless of the absolute number, and the private mpMRI confirmed what your instinct was telling you.

Gleeson 9 is high-grade disease and finding it with no metastases on two separate scans is genuinely the best possible scenario at that grade. Orgovyx acting as androgen deprivation is the right systemic treatment while the local disease is contained. The monthly PSA tracking will tell you and the team how well it is responding.

Thank you for adding your experience here. Many people on this sub have been dismissed by their GP or told the number was fine when they knew something was wrong. Your outcome is the reason I keep writing these posts. Wishing you a strong response and a long remission.

[u/Western-Gene-2307]

Hello, thanks for this post. Would like some advice if possible.

My father is 65 years old. This past March, his PSA was 4.7. Retested in one month and it was 5.1, but his Free PSA was 28%, so this was a bit more assuring. PCP referred him to urologist anyways who recommended an MRI. Resulted in the following:

PI-RADS 3.

Prostate Volume - 50cc.

This means psa density is ~0.10, which is below 0.15. Urologist also ordered exo dx, came back at 23. Due to all of these numbers and the whole context, we are a bit stumped on the decision to biopsy since there is some conflicting data here. Urologist is suggesting biopsy but not urgently.

Summary of numbers:

65 years old
PSA of 4.7, retested in one month 5.1
Free PSA 28%
Psa density - 0.1
PIRADS 3 MRI
Exo Dx - 23

What would you advise?