Deep Dive

What Your Elevated PSA Really Means

If you've recently received news about an elevated PSA, you might be feeling worried, confused, or even panicked. 

I've seen that look hundreds of times across my examining room. 

But before you imagine the worst-case scenario or, more dangerously, toss that lab report in a drawer and try to forget about it, here's something crucial: 

Our understanding of PSA has transformed completely in the last two decades.

We've gotten smarter about these numbers, and that knowledge changes everything about your next steps.

Why Smart Men Are Rethinking Everything About PSA Testing

If you’ve spent time online – or even in a doctor’s office – you may have heard that the PSA test is flawed.

That it leads to over diagnosis or unnecessary treatment. That most men die with prostate cancer, not from it.

There’s some truth in that history. But there’s also a bigger picture.

Decades ago, prostate cancer was often found too late – after it had already spread.

Then PSA testing changed the game. 

For the first time, we could detect cancer early, before symptoms appeared.

Naturally, we leaned in:

Let’s catch it early. Let’s not miss the dangerous ones.

And we did. But we also treated everything we found, including slow-growing cancers that never would’ve caused harm.

That led to overtreatment – and PSA got bad a reputation.

But we’ve learned. We've gotten smarter about who needs treatment and when. And yet, because of the controversy, fewer men were screened. 

Now we’re seeing more advanced, aggressive cases again – cases we could’ve caught earlier.

With this evolving perspective on PSA testing, the first step is understanding exactly what this test measures and what it doesn't.

Stop Misinterpreting Your PSA Number With This Simple Fact

PSA is not a cancer test. It’s a marker of prostate activity. All men with a prostate will have some PSA in their blood.

We usually start testing in a man’s 50s, or in his 40s if he's at higher risk – African American men or those with a family history of prostate cancer.

An elevated PSA doesn’t mean cancer. It could mean inflammation, infection, or just a larger prostate. 

It’s the start of a conversation, not a conclusion.

Once you understand what PSA actually measures, the next critical insight is how your very first test creates the foundation for all future comparisons.

The Foundation Number That Makes All Future PSA Tests Make Sense

Never had a PSA? 

Getting that first one in your 50s gives us a baseline. Down the road, we can track how it changes – and catch patterns that matter. 

One number means less than the trend.

While your baseline establishes a starting point, interpreting any PSA number requires something equally important. 

The context of your age and how your numbers change over time provides crucial perspective.

Why One PSA Number Means Nothing Without This Critical Context

For men in their 50s and 60s, a PSA under 4.0 ng/mL is typical. But we adjust for age – older prostates make more PSA. 

So we ask:

• Is the PSA rising steadily?

• Is it fluctuating?

• What's the free PSA?

• Any symptoms or risk factors?

Once a man reaches his 70s, we ask:

Does he likely have 10 – 15 years of life ahead?

If not, we often stop screening – not because it doesn’t matter, but because the benefits no longer outweigh the risks.

Understanding how age and trends affect your PSA leads to the most crucial distinction of all. 

This insight completely changes how you view the purpose of this test.

The Critical PSA Distinction Most Men Never Understand

I often tell men:

PSA doesn’t diagnose cancer. It helps us decide whether to do a biopsy.

Some men are ready. Others aren’t. That’s okay. But if you’re unsure, don’t disappear. 

Let’s retest. Let’s keep the conversation going. That’s how we make good decisions.

And as urologists, we need to make that space – to keep the door open, pressure-free.

When PSA leads to a diagnosis, many men are surprised to learn that immediate treatment isn't always the answer. 

Instead, there's a sophisticated monitoring approach that many doctors don't take enough time to explain.

When PSA leads to a diagnosis, many men are surprised to learn that immediate treatment isn't always the answer. 

Instead, there's a sophisticated monitoring approach that many doctors don't take enough time to explain.

The Prostate Monitoring Secret Doctors Don't Explain Well Enough

If biopsy shows cancer, about a third of men diagnosed will have low-risk disease that may not need treatment right away – or ever.

Those are the men we often follow with active surveillance:

• No surgery

• No radiation

• Just careful monitoring

But this isn’t “doing nothing.” It’s structured follow-up. 

About 30 to 50% of these men will eventually need treatment. 

The good news is, we’re watching – and we catch it early when treatment still works well.

This careful monitoring approach illustrates the true purpose behind PSA screening. This purpose is often misunderstood even by those who've had the test multiple times.

The Real Reason We Screen

We don’t screen to find all cancers. We screen to catch the cancers that matter.

The clinically significant ones. The aggressive ones. The ones that spread.

No blood test or scan tells us exactly how aggressive a cancer is. Only biopsy and pathology can do that.

That’s why we biopsy – not to overreact, but to get real answers. And if we wait too long, the chance for cure can pass us by.

Understanding the purpose of screening helps address what's really holding many men back. It's not fear of the test itself, but anxiety about what might come next.

Most Men Are Afraid of What Comes After

Many men avoid PSA testing not because they’re afraid of the number – but because they’re afraid of what might come next: treatment, side effects, decisions.

They worry about their independence, their relationships, their quality of life. That fear is real – even though modern treatments have improved dramatically.

But I always tell men, especially younger and healthier ones:

You have more to gain than you think.

Because early detection means more options. More control. Yes, there might be side effects –  but those can often be managed. 

What we can’t do is go back in time and catch a missed opportunity. These fears often crystallize around one procedure in particular. 

The biopsy seems intimidating, yet what many men discover is that this step brings clarity rather than more concern.

Why A Biopsy Brings More Peace Than You Think

If your PSA is rising – especially into the 8-9 range – it may be time to act. 

Even low-grade cancers don’t behave as well if diagnosed when PSA is over 10.

Biopsy gives clarity:

• Negative? You can be reassured – 95% of those truly don’t have cancer.

• Positive? Now you know what you’re dealing with.

Most men feel more peace after the biopsy than before – because now they’re not wondering.

It’s no longer what if? It’s what now?

Whether you're considering a biopsy or still assessing your PSA results, the single most important factor in your prostate health journey comes down to one straightforward approach.

The Simple Strategy That Leads To Better Prostate Outcomes Every Time

This isn’t about pushing tests or treatments. It’s about smart decisions, made with context and care.

You don’t have to say yes to everything. But don’t say nothing and disappear.

Because the men who stay in the conversation – who stay connected with their care – almost always do better.

Staying engaged leads to better outcomes. Every time.

Take this newsletter to your next appointment. Use it to start the conversation with your doctor about what your specific PSA number means for you. 

Ask about your baseline, your trend, and your risk factors. 

The more informed you are, the better decisions you'll make—and the better your outcome will be.

KEY TAKEAWAYS

• PSA trends over time matter more than any single number

• Staying engaged with your doctor leads to better outcomes

• An elevated PSA is the start of a conversation, not a diagnosis

• The peace of clear answers is worth the temporary discomfort

• Active surveillance is a structured approach, not "doing nothing"