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PSA test for prostate cancer

What may happen when a PSA test result is abnormal

If a man's PSA level is above normal there are no hard and fast rules and medical experts may not agree on the best course of action. What happens next depends on whether a man has symptoms, his personal risk of prostate cancer, and the PSA level. 

Not all men with a raised PSA level have prostate cancer, so if a PSA test result is 'at the top of the normal range' or slightly above 'normal' it may be repeated quite soon to check that the level wasn't raised because of other causes such as' ejaculation in the 48 hours before the test, or infection or inflammation of the prostate (prostatitis).

 

His PSA result was just above 4ng/ml, 'at the top of the normal range' so the GP decided to...

His PSA result was just above 4ng/ml, 'at the top of the normal range' so the GP decided to...

Age at interview: 70
Sex: Male
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So I came to see the doctor. He was rather reluctant to do the test because he said 'You don't get a very helpful indication, I think it tends to make you look iller than you are. But,' he said, 'If you ask for it I shall do it.' And I asked and it came out just above 4 which was enough to persuade him that we ought to continue [to test] every 6 months.

And your first tests were quite within normal range you were told?

They were at the top of normal range, high enough to make the doctor feel that it was worth going on with the series but not enough to persuade him that it was time to see a specialist.

Did you ever actually understand what a PSA stood for, what it meant? 

As far as I can recall it means prostate specific antigen and it is something which I presume occurs in the blood as a result of the action of cancer in the prostate.

Did anybody explain to you that other things might make the PSA a little bit above normal?

I'm sure that the doctor did though I can't remember him mentioning anything in particular. But he was very definite that you could get wrong indications which could cause worry without actually being helpful.

But after you had your PSA test and they were within normal range you went away feeling reassured then did you?

Well reasonably reassured but in the sense that the doctor had indicated I should continue it was something that one would have gone on indefinitely I think as long as it remained at that sort of level. 
 

One man we talked to had consulted his GP because he was very tired. After other test results were all negative his GP suggested a PSA test. The result was slightly higher than 'normal', so the test was repeated on two occasions. The PSA continued to rise so he was referred to a consultant.

 

His PSA test was only slightly higher than 'normal' so his GP decided to repeat the test.

His PSA test was only slightly higher than 'normal' so his GP decided to repeat the test.

Age at interview: 57
Sex: Male
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Right well I've been going to my doctor for a couple of years because I've felt very tired. I'd been working very hard, very, very long hours and I'd had a number of blood tests all of which had proved negative and she eventually said to me, 'I think it's about time you had a PSA test, you're 54, 55 years old let's see what that comes up with.' that was in March/April 03 and I'd just turned 54, 55. The first results were a reading of 4, I think, 4.2, and my GP said to me she was a little concerned about it, that it was slightly high and we decided that I would be tested again in a year's time. I think she said 9 months first of all. Because of commitments I eventually had the second test about 11 months later which was March/April 04. The result of that test was a reading of 8.2 and at that time my GP expressed some concern at the levels that were shown. There were, there was a possibility that the test was an incorrect reading so we had another test about 5-6 weeks later. She didn't actually know how long she had to leave it, it could've been left I think for, I believe now for about 3 days. Test in July 04 gave a reading of over 10 and alarm bells really rung then and I then went for, was referred to a specialist and went through for a biopsy, privately. The biopsy came up very, very positive, all of my biopsy samples were cancerous, the readings on the Gleason scale from 7 to 9 and alarm bells were really being rung then.
 

Another man who had a raised PSA test result was told that he could either be referred to a consultant or he could wait six months and then repeat the test. He decided to repeat the test and found that the second PSA result was lower than the first, so he was not referred.

 

His PSA was abnormal but having discussed it with his GP he decided to repeat the test after six...

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His PSA was abnormal but having discussed it with his GP he decided to repeat the test after six...

Age at interview: 72
Sex: Male
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Yes I had been a little bit worried about increasing frequency of urination, particularly at night time, not able to get through a night without getting up and sometimes twice at night. But I think I really started to take it seriously when I had quite severe backache because a friend of mine had suffered from very severe backache which they couldn't actually diagnose until eventually they found that it was a secondary cancer from the prostate and so I thought well backache and this urination perhaps I have a problem. So I went to see my GP and he did a number of, I did a blood test, which were for a number of things particularly the bones and other things too. And when, when I saw him again for the results he said everything was fine except the PSA test which is something I'd never heard of, I didn't really know what PSA meant. he said, 'You're right on the borderline with that.' So I said, 'Well what does that mean?' And he said, 'Well it means that there is a problem, you, and that there are several ways of dealing with it. I could refer you to the hospital and you could see a consultant and he would then decide whether you would have an operation or whatever was necessary or,' he said 'you could leave it for six months and have another blood test and see whether it had got worse in the meantime.' So being a coward I said, 'Yes that's what I'll do, I'll leave it for six months and have, have another blood test.' So he said, 'Fine that's what we'll do.' 

One man recalled that his GP told him that his PSA result was slightly raised, and then said it would be a good idea if he did a digital rectal examination before making any other decisions.

 

When he received his PSA result the GP suggested a digital rectal examination.

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When he received his PSA result the GP suggested a digital rectal examination.

Age at interview: 62
Sex: Male
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So yes had the test, had a phone call a bit later saying would I come back, they wanted to chat about the results of the test which I suppose was the first warning sign that you know they were only doing that because there was a problem. And I can remember at the time even on the phone saying, 'Are you sure you've got the right person [laughs] have you mixed me up because I'm not called by my first name?' and I can remember the woman saying yes and quoting my address back to me and 'You are that person aren't you?' because I think she was worried she'd rung the wrong person. And I said 'Oh yes that's me,' and I suppose that was the first time therefore that it flashed a kind of warning sign. So yes I went back to the doctor he basically said well, I mean he was very non-committal, in his mind he, in my mind anyway in his explanation he was riding the middle road. He said 'The result of the PSA is that it's a score of 5,' he said 'I don't see that as a particular negative, if you were 10 or 20 or higher it would a major, you know I would see it much more seriously so it's up to you if you want to go any further with it you can, but it does indicate that potentially there may be a problem and there may not be a problem. Do you want to follow it through further?' And in which case, and at that point he then explained the kind of next step which in his opinion was that a biopsy. But before then he said, 'Well look while you're here I'd like to examine it physically just to see if it's enlarged, whether in fact from my examination I can add anything to the result of the PSA test that might be helpful at this point in time in us making some decisions about the way ahead.' so he did examine it whilst I was there, not the most joyous experience but [laughs].

If a man's PSA result is 'abnormal' some GPs refer patients fairly rapidly to see a consultant urologist. The specialist may repeat the PSA test and digital rectal examination and conduct other tests, such as a cystoscopy. Having seen a consultant some men we talked to were told that they didn't need a biopsy and that their symptoms were due to a urinary infection or benign enlargement of the prostate.

 

The GP referred him to a consultant because he had urinary symptoms and a slightly raised PSA.

The GP referred him to a consultant because he had urinary symptoms and a slightly raised PSA.

Age at interview: 40
Sex: Male
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And I was given an appointment [with a urologist] possibly three, four weeks later. Popped in there and had to, I suppose we're moving on to the actual digital examination. But the PSA was fine, the PSA was fine, no problem at all. I did have a digital examination which was, as one knows [laughs] rather uncomfortable but you know thinking of my health and wellbeing it was just a minor inconvenience [laughs] so that wasn't a problem at all.

When happened when you got to the urologist, what did he say?

He continued, obviously looked through my paperwork, had a good chat as well again it was, I felt very comfortable with the gentleman, we developed some sort of rapport and he explained what was going to happen. Again it was going to be another digital examination so he just wanted to confirm that I'd had one before, I knew what the process was and he just made, tried to make the process as easy and comfortable as possible. We talked through a few things after, essentially he concurred with my GP saying that, eventually it just came out that I had an infection so that's what it made it [the prostate] slightly enlarged so I was prescribed some antibiotics but...

So it was an infection that was making you pass urine so frequently?

Yes, yes, yes, yes I suppose on the one hand that was the comforting result and but I didn't mind going through the process and I think in my mind I'd said well okay if it is this, I'm doing something about it early.
 

A consultant may recommend a trans-rectal ultrasound scan (TRUS) and a biopsy, even if the PSA is only slightly raised. One man we talked to had mild urinary symptoms, and a slightly raised PSA. Before agreeing to a biopsy he wanted to discuss what a positive biopsy result might mean and how side effects of any treatment might affect his quality of life. He was shocked when the consultant insisted that he ought to have a biopsy immediately. 

 

His consultant wanted to do a biopsy almost immediately.

His consultant wanted to do a biopsy almost immediately.

Age at interview: 57
Sex: Male
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Okay, basically my wife and I went to see the consultant, we've been together a long time so we're mutually very supportive. We went into see the consultant. He obviously did a rectal examination, he looked into my bladder to look at urine retention and that combined I think with the PSA of 4.8 led him to be very cautious about the fact that I may actually have cancer, not necessarily have cancer but I may have cancer so he wanted to pursue further testing straight away. 

Obviously I wanted to talk to him about what this might mean to me, what the various treatments might mean, whether or not this would have any side-effects or what have you. So he talked about treatments but basically focused on TURP which is his specialty and he talked, talked about it as being the Gold Standard. And I said we've been together for a long time, we had a very good intimate relationship and I was a bit concerned about the side-effects in terms of my sexuality and so on. It was quite shocking really because within sort of you know 5, 10 minutes of having this discussion, obviously he'd done the examinations and what have you but when my wife and I were together with him within 5 or 10 minutes he was saying, 'Well I just want you to know, you know you cannot have sex from a coffin.' And when he didn't get the sort of reaction probably he was expecting he then said, 'Especially if the lid is screwed down.' which I thought was quite a tricky thing to say to somebody when he'd first met them. 

So anyway this was a Friday and he said, 'Well you'd better come in on Monday for biopsies.' So I was thinking hell am I going to die or something, you know it's Friday, the next possible day I could come in for biopsies was the Monday. So he booked me in for biopsies on the Monday and to come back to him for the results on the following Friday.
 
 

He wanted to discuss how treatment might affect quality of life before agreeing to have a biopsy.

He wanted to discuss how treatment might affect quality of life before agreeing to have a biopsy.

Age at interview: 57
Sex: Male
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You said something just then about quality of life, would you mind just summarising that?

Well I'm very fortunate I do not have cancer but of course during this whole process what concerned me greatly was my quality of life. I've been married for 35, 36 years, I have a wonderful relationship, it's a full relationship which includes all the physical love aspects of a relationship, and it's very important to me, it's very important to my quality of life. In discussing this with the consultant I'm afraid we just couldn't go there because he was talking about cancer and he was talking about the possibility of dying from cancer, and I was talking about my quality of life, not the quality of my death. And this whole issue of, well as a consultant who is dealing with cancer of the prostate he's just seen so many people die of cancer of the prostate he is worried about saving lives. And my concern was of course in saving my life but in saving my life including my quality of life, and the constant discussion about TURP which is basically an apple corer and you stick an apple corer in, you core out what's in there, all your nerve endings, everything else, so that if you're lucky enough actually not to become impotent then what happens is you'll have retrograde ejaculate if you ejaculate at all. And basically the whole thing, if you have to go through it you have to go through it but if you can avoid going through that, for me anyway I would attempt to avoid going through that. So if it got to the, to the wire and I found that I did have cancer I have to say I would not have gone for treatment locally. 

If a man's PSA level is raised much above 'normal' he will certainly be referred to a specialist, who will probably recommend a biopsy. (For more about prostate biopsies see 'Biopsy of the prostate' and also the our prostate cancer section). 

Last reviewed May 2016.

Last updated May 2016.

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