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Johns Hopkins Health Alert

Refining What PSA Levels Mean

In this excerpt from a recent issue of Health After 50, H. Ballentine Carter, M.D., Professor of Medicine at the Johns Hopkins Hospital, discusses current trends in PSA testing.

Since the prostate specific antigen (PSA) test became widely used in the 1990s, prostate cancer deaths have dropped dramatically. Today one of the biggest problems with PSA testing is that it detects many cancers that are not life threatening and would never have been diagnosed or treated otherwise, especially among older men.

Q. How does PSA testing result in overdiagnosis?

Dr. Carter: PSA levels are most often elevated for reasons other than cancer, such as prostatic enlargement (benign prostatic hyperplasia -- BPH) or prostatic inflammation, which are common among aging men. In addition, many men with these conditions also have small prostate cancers that are also common with age but usually do not progress.

The PSA test cannot differentiate between dangerous cancer and benign conditions, so when biopsies are based on elevated PSA test results, prostate cancers are often found serendipitously; many of these would not have been found otherwise. This over diagnosis of prostate cancer has been estimated to occur in 30–50% of men between ages 55 and 80 years. Over 85% of prostate cancers detected are treated when diagnosed. Thus, over treatment of cancers that would not have caused harm is a byproduct of screening.

The extent to which PSA testing for the early diagnosis of prostate cancer results in more benefit (reduction of prostate cancer deaths) versus harm (detection and treatment of prostate cancers that would not have caused harm) is hotly debated. Nevertheless, physicians and patients prefer the risk of unnecessary treatment to missing a potentially lethal cancer. The solution to the dilemma is a test that can differentiate between life- threatening and indolent prostate cancer before a biopsy takes place.

Q. In the meantime, how are doctors trying to reduce the number of needle biopsies and over diagnosis?

Dr. Carter: Currently, annual PSA testing beginning at age 50 is recommended, but newer guidelines will stress the need for a baseline PSA test at age 40, another one at 45, and then an annual or biennial PSA test beginning at age 50 depending on the PSA level. By starting to accumulate a PSA history at age 40, a man will have measurements to compare with levels obtained in his 50s in order to determine the rate his PSA changed -- his PSA velocity—a useful measure of the presence of a life-threatening cancer.

PSA levels vary a lot over the short term (6 months). It is important to have a PSA history of more than two years to evaluate PSA velocity accurately. If PSA velocity is consistently above 0.4 ng/mL per year in a man with a PSA level below 4.0 ng/mL, prostate cancer should be suspected and a biopsy considered. In men with PSA levels between 4 and 10 ng/mL, a PSA velocity of 0.75 ng/mL per year suggests the presence of prostate cancer.

Posted in Prostate Disorders on June 19, 2008
Reviewed July 2009

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Health Alerts registered users may post comments and share experiences here at their own discretion. We regret that questions on individual health concerns to the Johns Hopkins editors cannot be answered in this space.

The views expressed here do not constitute medical advice, and do not represent the position of Johns Hopkins Medicine or MediZine LLC, which has no responsibility for any comments posted on this site.


I am a 68 year old male who was diagnosed with a "boggy prostate" starting in my mid 30s. I started having PSA tests run in 1992. Only one time (7-1995) have I had a level below 4.0 w/o medication. I have had three negative biopsies in the last 14 years. I have had numerous prostate infections since my 30s. However since being on Proscar and it's generic, I have not had an infection in 2 years. There needs to be a better test for those like my self that suffer from prostatic enlargement (benign prostatic hyperplasia -- BPH) and/or chronic prostatic inflammation.

Posted by: dlemon | June 21, 2008

The article was interesting. But I thought I recently read something similar. So went to my Prostate file and Voila.I was right. In october 2007 the Johns Hopkins Health After 50 monthly magazine had verbatim the same article entitled Prostate Screening: Refining What PSA Levels Mean. So I ask: why was an eight month old article recycled in June of 2008?.

I was under the impression that Johns Hopkins was always on the cusp of health information. I'd appreciate a reply.

Thanks. DD

Posted by: dd | June 21, 2008

DD: You're right -- this article was excerped from an earlier Health After 50 article. We felt the information would be of great value to a wider audience, many of whom did not have the chance to read it in the newsletter -- which is why we used it as a Health Alert. And by the way, the informaton is still quite timely. Editor

Posted by: Marjorie | June 23, 2008

I've read about a new test that was developed at John Hopkins to not only detect early prostate cancers but also how aggressive they are. It is called EPCA-2. What is the status of this test? Is it in clinical trials? If so, where and how would one enroll in a trial?

Posted by: JM211 | July 6, 2008

The EPCA test information is here at the site: EPCA-2 Test Article

and at the bottom of the page is all the contact information you need to find out more about enrolling in the trial.

Posted by: Jo | July 30, 2008

My husband was diagnosed with prostate cancer,which had gone into some of his bones. His PSA level was extremely high at the time. He started taking treatments and his PSA went down drastically.He was also taking CASADEX. After awhile on the CASADEX his PSA went up. His doctor took him off the CASADEX,and the PSA went back down. It started going back up again,so he was put back on the CASADEX....now it us going back up. How high does his PSA have to get before we should really start worrying? Has this type of cancer ever been cured?

Posted by: dolphin | February 9, 2009

I have some serious reservations about Johns Hopkins and the information it disseminates about prostate cancer.

If I were to have listened to the information offered in your White Paper, I would have subjected myself to needless biopsy. As it is, there is enough hysteria in the field. You folks seems to be selling surgery at every turn.

My urologist called me in hysterics one night telling me based on my PSA (3.9, Free PSA 17%) I was at 25% risk of prostate cancer. He allowed that he would be happy to biopsy and if so much as one cancer cell was found he could do a radical prostatectomy and have me "home the next day." "Wow", I asked... "you mean you can have me home, incontinent and impotent the very next day?" He failed to see my sarcasm and issued another warning about how I was burying my head in the sand.

In reality I was suffering from prostatitis which was cured with a course of Levaquin and elimination of spicy food and alcohol. Indeed a graph I keep shows my free PSA has been in the same range +/- for the last ten years. There was no PSA velocity, and he should have known that. Needless to say I stopped seeing this doctor. But he, like so many others, is maiming men just like women were maimed years ago with needless mastectomies.

It would behoove you to remind your readers in each and every article that prostate cancer is common, the deadly form is not, the rate of growth is usually slow and most men will die with prostate cancer not from it.

Oh, lo and behold, 2 years after that hysterical call from the doctor who could not wait to do a biopsy, at age 60 my last PSA was 2.7 and free PSA was 25%. All quite normal given my history.

If you are going to provide information of people provide ALL of it and avoid fanning the flames of hysteria.

Posted by: teddavid | May 9, 2009

I have some serious reservations about Johns Hopkins and the information it disseminates about prostate cancer.

If I were to have listened to the information offered in your White Paper, I would have subjected myself to needless biopsy. As it is, there is enough hysteria in the field. You folks seems to be selling surgery at every turn.

My urologist called me in hysterics one night telling me based on my PSA (3.9, Free PSA 17%) I was at 25% risk of prostate cancer. He allowed that he would be happy to biopsy and if so much as one cancer cell was found he could do a radical prostatectomy and have me "home the next day." "Wow", I asked... "you mean you can have me home, incontinent and impotent the very next day?" He failed to see my sarcasm and issued another warning about how I was burying my head in the sand.

In reality I was suffering from prostatitis which was cured with a course of Levaquin and elimination of spicy food and alcohol. Indeed a graph I keep shows my free PSA has been in the same range +/- for the last ten years. There was no PSA velocity, and he should have known that. Needless to say I stopped seeing this doctor. But he, like so many others, is maiming men just like women were maimed years ago with needless mastectomies.

It would behoove you to remind your readers in each and every article that prostate cancer is common, the deadly form is not, the rate of growth is usually slow and most men will die with prostate cancer not from it.

Oh, lo and behold, 2 years after that hysterical call from the doctor who could not wait to do a biopsy, at age 60 my last PSA was 2.7 and free PSA was 25%. All quite normal given my history.

If you are going to provide information of people provide ALL of it and avoid fanning the flames of hysteria.

Posted by: teddavid | May 9, 2009

I am a 62 year old male who has just received a lab report indicating that my PSA level is 1.4. The VA Dr. suggested "internal testing" and I am not quite sure of how to proceed.

Is the 1.4 level cause for concern or should I have additional lab testing?

Thanks Bernie

Posted by: bbrosnihan | January 19, 2010

Nowhere does this article comment that it is NOT a single PSA number, but a progression over a period of time... say, is the level increasing over 2 or more screenings... the misconception on "what to do" with the results of any one screening has led to this "controversy"... my levels kept rising for 6 years before breaching your "magic number" of 4... Since my "event",I have worked with over 900 men... have data on men diagnosed with pc as young as 32... with PSA levels in the 7's and not pc, and one at 2.85 with the disease... how many doctors advise men to avoid sex prior to having blood drawn?... the problem here is, sadly, a lack of a true understanding of the test, what the numbers mean,... and how to proceed...

When my pc was being diagnosed, my doctor, correctly, first treated me for an enlarged prostate and BHP... as well as a thorough "interview" to determine if there any other possible causes... and with antibiotics... ONLY then, when these were eliminated did he order a biopsy... proper medical procedure... and not a "rush to test"...

I also note the lack of any discussion of Free-PSA...

Are you providing medical advice or writing for USA Today and the Enquirer...

Posted by: GotDOCG | January 23, 2010



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