PSA and Prostate Cancer

"An elevated PSA value in itself is not a diagnosis of prostate cancer, since it is also associated with other pathologies such as benign prostatic hyperplasia or prostatitis".

DR. BERNARDINO MIÑANA LÓPEZ
CODIRECTOR. UROLOGY DEPARTMENT

Prostate cancer is the third most common tumor in Spanish men and is the third leading cause of cancer death in Spain. The incidence of this cancer increases with age. Some are slow growing and have no clinical manifestations throughout life, while others are more aggressive and can metastasize.

Prostate-specific antigen (PSA) is a protein produced by the prostate that participates in the dissolution of the seminal clot. Its production depends on the presence of androgens and the size of the prostate gland. It is practically an exclusive synthesis protein in the prostate. It is known as a tumor marker for prostate cancer. The elevation of PSA in plasma is proportional to the tumor mass present, and so PSA in blood is a great test for detecting the presence of prostate cancer.

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When is PSA indicated?

A very small part of the PSA produced by the prostate passes into the bloodstream and it is precisely this that is measured for the diagnosis, prognosis and follow-up of prostate cancer.

The reference values for serum PSA vary according to the different laboratories, although normally they are 4 ng/mL.

Blood levels of PSA can vary in certain situations. In healthy men, the levels are very low. In a hospitalized patient, levels can drop by as much as 50%. Ejaculation or physical exercise can also modify PSA levels.

Prostate massage or prostate biopsy can temporarily raise serum PSA levels. In tumor processes, it is common to find values above normal.

Patients with prostate cancer have a lower percentage of free PSA, while those with benign prostatic hyperplasia have a higher proportion.

Most frequent indications of this test:

PSA levels correlate with tumor size and spread, i.e., PSA levels will be higher the larger and more widespread the tumor is. However, a certain percentage of prostate cancer patients have normal PSA levels.

Elevated PSA levels can also occur in other prostate pathologies such as benign prostatic hyperplasia or prostatitis. Therefore, an elevated PSA value in itself is not a diagnosis of prostate cancer, although it is of great help to the urologist for its diagnosis along with other tests such as the digital rectal exam.

In the case of an elevated PSA value in isolation, it is advisable to confirm these elevated levels after some time, and another test that can be performed is the so-called free PSA.

Do you have any of these diseases?

A PSA determination may be necessary

Monitoring of PSA levels

Once a diagnosis of prostate cancer is established, PSA is especially useful in monitoring the effectiveness of therapy.

For this purpose, it is very important that PSA measurements are always performed with the same technique and, if possible, in the same laboratory. This ensures that the variations found are due to the evolutionary process of the tumor and are not technical alterations.

The way in which the serum PSA levels are lowered depends on the therapy chosen:

  • Patients who have undergone radical prostatectomy have to have their PSA levels fall to undetectable levels after approximately one month if all the tissue has been removed. A later elevation of these levels would mean recurrence of the tumor.
  • To monitor these patients who have had their prostate removed, a type of "ultrasensitive" PSA determination method is used, which has the particularity of detecting PSA levels as low as 0.01 ng/mL.
  • If the treatment is with radiotherapy, the levels slowly decrease until they stabilize around the reference range.
  • There may be a transient increase in PSA levels during radiation therapy, which is not a sign of disease progression. Recurrence would be suspected by an increase in PSA levels.
  • Hormone therapy also decreases PSA levels to baseline values, this time for two reasons, firstly because it decreases this androgen-dependent production, and secondly because it decreases the tumor burden.

The cut-off point of normal levels also increases with the age of the patient. Thus, a serum PSA level of 4 ng/mL can be considered elevated in a 50-year-old person and normal in an 80-year-old.

PSA levels vary randomly in the order of 15% in the same individual.

Thus, a PSA analysis of 3 ng/mL can be repeated on another occasion and could give a result of 3.2 or 2.8 ng/mL naturally.

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