Total PSA and Free PSA are very important screening tests to evaluate prostate health.
However, they should not be routinely applied to everybody. But why is that? This is a screening method for prostate cancer. So, why do doctors choose who is a candidate for a PSA test?
As you will see in this article, PSA levels can be tricky to interpret. They can lead to false positives if not correctly used.
Many factors can interfere and cause a temporary PSA elevation in a healthy person. But can stress affect PSA levels? Let’s find it out.
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What is PSA?
PSA stands for Prostate Specific Antigen. It is a substance produced by the prostate gland. This gland is located below the bladder, surrounding the bladder neck.
The function of the prostate is to provide a liquid that helps sperm in the process of conception. One of the substances the prostate releases along with the sperm, is the PSA. This is a particular protein that breaks down the agglomerations of sperm. Thus, the resulting sperm is more fluid and moves more easily in the vagina and the uterus.
PSA is meant to be released to the sperm. However, it is normal to find a small fraction in the blood as well. A given proportion of PSA always leaks to the blood, but the amount is usually minimal. However, this proportion can be affected by various factors. For example, when prostate cells undergo inflammation and other prostate problems (1).
Younger men usually have lower PSA levels because they don’t have any prostate problems. As they grow older, it is normal to have increasing levels of PSA. This is usually because the prostate becomes slightly enlarged as we age.
However, after reaching certain levels, and in certain people, a higher PSA may reflect, we need treatment for a prostate condition.
What is the significance of a high PSA level?
Elevated PSA levels can be associated with various conditions, including prostate cancer, benign prostatic hyperplasia (BPH), inflammation, and medical procedures involving the prostate gland. However, it’s essential to note that a slightly enlarged prostate may not always result in high PSA levels.”
Or they simply experienced inflammation or a procedure in a normal prostate. As you can see, there’s a wide variety of conditions and circumstances. Thus, an elevated PSA level is not always indicative of cancer.
In short, we can say that PSA can become elevated in these circumstances:
- Prostate cancer: PSA is usually higher in cases of prostate cancer. In most cases, prostate cancer cells have a similar function and create PSA. As the gland grows bigger, it produces and leaks more PSA to the blood. A slight increase may be seen in early prostate cancer. In advanced prostate cancer, there can be a more noticeable increase in PSA levels, but it’s crucial to understand that the relationship between PSA levels and cancer progression varies among individuals (2).
- Biochemical recurrence of prostate cancer: PSA elevation after hormone therapy or radiation therapy can be due to a biochemical recurrence of prostate cancer. In these cases, patients may not have symptoms of prostate cancer. However, their PSA levels should be estimated to evaluate recurrence (3).
- Benign prostatic hyperplasia: Most cases of PSA elevations are due to benign prostatic hyperplasia. Benign prostatic hyperplasia (BPH), commonly known as BPH, is often expected, particularly in older adults after the age of 60. 90% of patients over 80 years old have BPH. Thus, it is very likely men will get a higher reading at some point in their lifetime (4).
- Enlargement of the aging prostate: Even if men do not have BPH, they do experience an enlargement of the prostate as they age. Thus, it is expected to have rising levels of PSA as we age. Performing a PSA exam and using it as a baseline can be important in certain situations, but it’s crucial to consider individual factors and make informed decisions about testing. (4).
- Inflammation and other prostate conditions: Certain prostate diseases, such as prostatitis, can lead to higher PSA levels. However, not all prostate diseases result in elevated PSA concentrations. Especially when there is infection or inflammation of the prostate. This is known as prostatitis and can be a cause of an elevated PSA concentration. Other inflammatory conditions can have the same effect. For example, urinary tract infections (1).
- Medical procedures that involve the prostate gland: Besides prostate disease, certain medical procedures can increase PSA levels. One classic example is a digital rectal exam or prostate massage (5).
- Other factors: A variety of additional factors can affect the concentration of PSA in the blood. Thus, it is recommended to evaluate each patient separately. While an increase in PSA can be indicative of various factors, it’s essential to consider each patient individually. Occasionally, measurement errors can occur, and some doctors may recommend a second measurement from another lab for confirmation.
As you can see, there’s not one single significance of high PSA. It can be a variety of things and factors that come into play in a given individual at a given time. That’s why it can be some uncertainty as to when to use PSA measures. And some people may question how accurate it is to detect prostate cancer.
Is the PSA test accurate?
PSA test accuracy is questionable because there many factors interfere with the measurement. A false measurement can prompt a prostate biopsy. This procedure is useful for detecting prostate cancer. However, it has consequences that affect the quality of life of patients.
A prostate biopsy can cause chronic bleeding and chronic pain. The site of the procedure can become infected and bring along other problems. While a false positive result can lead to pain and bleeding, it’s crucial to consider the potential benefits of early cancer detection through a biopsy. Thus, PSA accuracy is very important if we want to use PSA screening for prostate cancer.
Given the potential for misleading results, PSA testing is selectively recommended for patients with urinary symptoms or risk factors for prostate cancer. If you have urinary symptoms or risk factors for prostate cancer, you’re a candidate. Patient eligibility for PSA testing varies, and the decision should be made in consultation with a healthcare expert based on individual factors.
Still, PSA remains beneficial for urologists. Along with the Gleason score, it is used to evaluate how aggressive cancer is. It can help your urologist to decide if he’s going to perform a radical prostatectomy. It is also valuable for patients undergoing active surveillance, a strategy employed by doctors for senior patients with non-aggressive cancer, where the approach involves monitoring rather than immediate intervention (6)
Now, transitioning to those concerned about ruling out cancer, additional measures can enhance the accuracy of the PSA test. In specific cases, complementary measurements such as PSA velocity, which monitors the speed of PSA level rise, and PSA density, calculated by dividing total PSA by prostate volume in ml, can be employed to increase the accuracy of the PSA test (6):
- PSA velocity: It is constant monitoring of the PSA. After obtaining results and comparing them with a time table, we can see how fast PSA levels rise. A very rapid increase can be indicative of prostate cancer.
- PSA density: It combines the measurement of the prostate and that of the PSA. It is simply dividing the total PSA by the prostate volume in ml.
Can stress affect PSA levels?
Stress can affect many health parameters. We have clear examples like inflammatory arthritis or psoriatic arthritis. These and other inflammatory conditions are triggered by stress. If not triggered, they can also be worsened, causing severe flare-ups.
Does the same happen with prostate patients? Chronic or acute stress likely causes an inflammatory process. This inflammatory process may affect the prostate and increase PSA levels. But while it appears reasonable in theory, there is not sufficient evidence to back it up.
Still, some sources of physical stress will definitely cause a rise in PSA. For example, a surgical procedure, and undergoing trauma as in a car crash, are more likely associated with a high PSA. This is particularly true in cases where the surgical procedure or trauma directly impacts the prostate. Psychological stress has a different association with prostate problems compared to its association with PSA levels. It indirectly influences prostate health more than PSA readings (5).
To evaluate this relationship, a study was performed at the University of Iowa. There were patients with BPH medications. Others were not taking any medication. They were evaluated thoroughly and answered questions about stress. Researchers found that people with a higher level of stress were more likely to suffer from BPH symptoms. If they already had BPH, their symptoms were significantly worse (7).
Moreover, stress has been linked to the occurrence of various cancer types, though it’s important to note that stress is not considered an independent risk factor in this field. While it may play a role, it does not directly cause prostate cancer.
The reverse is true because PSA measurements can cause stress. This is especially the case when patients are scared about their results and do not know much about prostate cancer. This can be counterproductive because, as we explained above, this can make their symptoms worse. It’s important to recognize that symptoms exacerbated by stress may lead to challenges in accurately assessing a patient’s condition, emphasizing the need for clear communication between patients and healthcare professionals.
The possibility that stress may trigger inflammatory reactions in the prostate, akin to arthritis, is still a topic of debate and ongoing research. While it is a reasonable hypothesis, conclusive evidence is not yet available. Thus, to avoid the possibility, it is always appropriate to reduce stress and anxiety when testing for PSA levels.
It often comes from thinking about prostate cancer and not knowing what will happen. But rest assured that you’re in good hands and already doing what you’re meant to do in favor of your health.
What other factors can influence PSA?
Many other factors can influence PSA levels at a higher and measurable rate. You can have a high PSA level in the following cases:
- High levels of parathyroid hormone: Hormonal levels can affect the function of the prostate gland. The parathyroid hormone regulates the balance of calcium in the body. A very high level can also increase the chance of BPH and prostate cancer. Thus, individuals with elevated levels of parathyroid hormone may be at a higher risk, potentially leading to an increased chance of registering a high PSA reading (8).
- After ejaculation: Ejaculation and sexual activity directly stimulate the prostate gland. It releases its contents and may also leak PSA to the blood. Therefore, it is generally recommended to avoid sexual activity for 48 hours before a PSA test, as ejaculation and sexual activity can directly stimulate the prostate gland, releasing its contents and potentially affecting PSA levels.
- Medications: Some medications affect your PSA levels. And, ironically, some of them are used to relieve prostate symptoms. For example, finasteride is commonly used to improve urinary problems in BPH. This drug will also reduce the level of PSA. The end result is a lower PSA, but not because the problem is getting better. It can result in a skewed reading that may pose challenges for both doctors and patients in interpreting the results. Therefore, your doctor may recommend discontinuing finasteride treatment before testing your PSA levels (9), but this decision should be made under the guidance of a healthcare professional.
There are still other factors that influence BPH and may indirectly modify PSA levels. We all have to look out for additional risk factors and try to prevent (2):
- Smoking: According to studies, cigarette smoking can increase the risk of BPH. The increase is surprising in people who smoke heavily (35 cigarettes a day). These are 50% more likely to suffer from severe BPH symptoms. Other studies have also confirmed these findings. It is evident, then, that this is a lifestyle factor we aim to address.
- Obesity: The same study that evaluated smoking also evaluated obesity as a risk factor. Having a waistline of 43 inches and more can increase your BPH risk more than twice the normal risk. Thus, the recommendation of physical activity and weight control is fundamental. Regular physical activity not only improves cardiovascular health but is also associated with a reduction in prostate risk.
- Low exercise levels: Interestingly, living a sedentary life can affect your prostate, too. Physical activity exerts an influence opposite to stress on the nervous system, potentially improving urinary symptoms and contributing to a 25% reduction in the risk of BPH. Even moderate activities like 15 to 30 minutes of daily walking can have a positive impact. It may actually improve urinary symptoms and help patients recover. It is also associated with a 25% reduction in the risk of BPH. You don’t need to engage in strenuous physical activity. It is enough with 15 to 30 minutes of walking every day.
- Alcohol: Naturally, this drink is heavily diuretic. It makes you increase the urinary output and worsens the symptoms of BPH. Thus, it may be appropriate to limit alcohol consumption. This won’t increase your PSA levels, but it is a lifestyle modification we should also consider.
Prostate cancer screening is essential to rule out cancer. However, it should not be performed in each and every patient. That’s because false positives are always a possibility, especially when it comes to PSA screening.
While PSA levels tend to increase with age, it’s important to note that normal levels can vary widely among individuals, and age alone does not determine normal or abnormal levels. This is completely normal but reduces PSA’s accuracy if we don’t have a baseline level to compare. That’s why other tools are made available to increase the accuracy of PSA measurements.
Nevertheless, preventing a false PSA reading can be challenging, as readings may be influenced by various factors beyond individual control. Certain types of inflammation or infection affecting the prostate may lead to increased PSA levels. Even a urinary tract infection can cause a higher PSA level. Sexual activity, manipulation of the prostate, and some medications may also modulate the PSA level.
Stress can also affect PSA levels. Similar to what happens in chronic inflammatory problems, stress can trigger the immune system. In a theoretical scenario, it may cause prostate inflammation and PSA release to the blood. However, there’s no clear evidence that this is the case.
What we do know for sure is that PSA screening often puts patients in a stressful situation. If you experience stress before a PSA screening, seeking information from your doctor about your current health status and the reasons for the PSA measure can be key to relieving that stress. Discussing your concerns with your healthcare provider may also provide reassurance.
Ask your doctor about your current health problem and why is he asking a PSA measure. Try not to feel alarmed without reason, and remember that you’re doing the right thing by following recommendations by your doctor.