PSA Screening Test for Prostate Cancer

Screening is testing to find cancer in people before they have symptoms. The American Cancer Society recommends that men be screened for prostate cancer with the prostate-specific antigen (PSA) blood test, starting at age 50 if they are at average risk, or at age 45 if they are at higher risk. To learn more, see American Cancer Society Guideline for Prostate Cancer Early Detection.

What is the prostate-specific antigen (PSA) blood test?

Prostate-specific antigen (PSA) is a protein made by cells in the prostate gland. A small amount of PSA enters the blood, where it can be detected as a biomarker by a blood test.

The PSA level is measured in units called nanograms per milliliter (ng/mL).

What PSA level might mean cancer?

PSA is made by both normal cells and cancer cells in the prostate, so it’s normal to find some PSA in any man’s blood.

The chance of having prostate cancer goes up as the PSA level goes up, but there is no set cutoff point that means for certain a man has cancer.

Doctors might use different PSA cutoff points when deciding if a man might need further testing. The American Cancer Society recommends further testing if the PSA level is 3 ng/mL or higher in men younger than 70. Some doctors might recommend further testing starting at different PSA levels, such as 2.5 or 4. If you’re getting a PSA test, ask your doctor what cutoff level they use when deciding whether further testing might be needed.

Age-specific PSA

PSA levels are normally higher in older men than in younger men, even when there is no cancer. For this reason, some screening guidelines use age as a factor in determining the cutoff PSA level for when further testing should be done, especially in older men. For men aged 70 and older, the American Cancer Society recommends further testing starting at a PSA level of 6.5 ng/mL.

Other ways to look at PSA

Because the PSA level itself can’t tell for sure whether a man has prostate cancer, doctors have looked for other ways to help make the PSA results more meaningful.

What else affects PSA levels?

One reason it’s hard to use a set cutoff level with the screening PSA test is that factors other than prostate cancer can also affect PSA levels.

Factors that might raise PSA levels include:

• Having an enlarged prostate: Conditions such as benign prostatic hyperplasia (BPH), a noncancerous enlargement of the prostate that affects many men as they grow older, can raise PSA levels.
• Prostatitis: This is an infection or inflammation of the prostate gland, which can raise PSA levels.
• Ejaculation: This can make the PSA go up for a short time. Your doctor might suggest abstaining from ejaculation for a couple of days before testing.
• Riding a bicycle: Some studies have suggested that cycling may raise PSA levels for a short time, possibly because the seat puts pressure on the prostate.
• Certain urologic procedures: Some medical procedures that affect the prostate, such as a prostate biopsy or cystoscopy, can raise PSA levels for a short time. Some studies have suggested that a digital rectal exam (DRE) might raise PSA levels slightly, although other studies have not found this.
• Certain medicines: Taking male hormones like testosterone, or other medicines that raise testosterone levels, may cause a rise in PSA.

Some things might lower PSA levels, even if a man has prostate cancer:

• 5-alpha reductase inhibitors: Certain drugs used to treat BPH or urinary symptoms, such as finasteride (Proscar or Propecia) or dutasteride (Avodart), can lower PSA levels. These drugs can also affect prostate cancer risk (discussed in Can Prostate Cancer Be Prevented?). Tell your doctor if you are taking one of these medicines. Because they can lower PSA levels, the doctor might need to adjust for this.
• Herbal mixtures: Some mixtures that are sold as dietary supplements might mask a high PSA level. This is why it’s important to let your doctor know if you are taking any type of supplement, even ones that are not necessarily meant for prostate health. Saw palmetto, an herb used by some men to treat BPH, does not seem to affect PSA.
• Certain other medicines: Some research has suggested that long-term use of some other medicines, such as aspirin, statins (cholesterol-lowering drugs), and thiazide diuretics (such as hydrochlorothiazide) might lower PSA levels. More research is needed to confirm these findings.

It’s important to talk to your doctor about anything you’re taking that might affect your PSA level, because it might affect the accuracy of your test result.

Can I use an at-home PSA test?

Some companies now offer PSA test kits that let you collect a blood sample at home, typically from a finger stick, and then send it to a lab for testing. This could be more convenient for some men, and it might even allow some men to be tested who otherwise might not be.

However, at-home testing might not give you the chance to talk with a healthcare provider about the pros and cons of prostate cancer screening before being tested. This informed decision-making is an important part of the American Cancer Society Guideline for Prostate Cancer Early Detection.

Another important issue is that PSA blood test results can’t tell you for sure whether you have prostate cancer. If you get an at-home PSA test, it’s important to discuss the test results with a health professional who understands what the results mean for you.

What happens if my PSA screening test result isn’t normal?

Having a high PSA level doesn’t always mean you have prostate cancer. But if a screening test shows your PSA level is higher than normal, further testing will be needed to find out why. Your doctor may recommend one of these options:

• Waiting a while and then repeating the PSA test
• Getting another type of test to get more information about whether a prostate biopsy is needed
• Getting a prostate biopsy to find out if you have cancer

Talk with your doctor about your options, including their possible risks and benefits. Factors that might affect which option is best for you include:

• Your age and overall health
• The likelihood that you have prostate cancer based on tests done so far
• Your own comfort level with waiting or getting further tests

If your initial PSA test was ordered by your primary care provider, you may be referred to a urologist, a doctor who treats prostate cancer and other diseases of the genital and urinary tract, for this discussion or for further testing.

Repeating the PSA test

Your blood PSA level can vary over time for a number of reasons, so doctors typically recommend waiting at least a couple of weeks and then repeating the test if the initial PSA result is abnormal. You might be advised to avoid activities that could raise your PSA level, such as bicycling or ejaculation, in the days before the repeat PSA test.

Repeat testing is most likely to be a reasonable option if the PSA level is slightly higher than normal. For very high PSA levels, doctors are more likely to recommend getting other tests, or even going straight to a prostate biopsy.

Getting other tests

If your initial or repeat PSA result is higher than normal, your doctor will likely recommend other types of tests to help decide whether you need a prostate biopsy.

Getting a prostate biopsy

A prostate biopsy is a procedure in which small samples of the prostate are removed and looked at under a microscope. A biopsy might be recommended after a screening PSA test, especially if the level is very high. More often, a biopsy is recommended if the results of one or more of these other types of tests are concerning.

A biopsy is the only way to know for sure whether you have prostate cancer. If prostate cancer is found on a biopsy, this test can also help tell how likely it is that the cancer will grow and spread quickly, which can help determine whether it needs to be treated right away.

For more details on the prostate biopsy, including how it is done and what the results might mean, see Tests to Diagnose and Stage Prostate Cancer.

Does insurance cover prostate cancer screening?

The American Cancer Society (ACS) supports legislation ensuring that men have insurance coverage for prostate screening tests. Men shouldn’t be prevented from getting prostate cancer screening because of testing costs, lack of health insurance coverage, or lack of access to testing.

State efforts to ensure prostate cancer screening coverage

Many states have laws requiring that private health insurers cover tests to detect prostate cancer, including the PSA test and DRE. Some states also ensure that public employee benefit health plans provide coverage for prostate cancer screening tests.

Most state laws ensure annual coverage for men ages 50 and over and for high-risk men, ages 40 and over. “High-risk men” typically refers to Black men and/or men with a family history of prostate cancer. Some states have slightly different coverage requirements.

Laws on coverage vary from state to state, so check with your insurer or with your state insurance commissioner’s office to learn what’s covered.

Medicare coverage

Medicare Part B covers a PSA blood test and a DRE once a year for all men with Medicare age 50 and over.

PSA test: You pay nothing for a yearly PSA blood test. If you get the test from a doctor who doesn’t accept Medicare assignment, you may have to pay a fee for the doctor’s services, but not for the test itself.

Digital rectal exam: If your doctor does this test, you pay 20% of the Medicare-approved amount for a yearly DRE and for your doctor’s services related to the exam. The Part B deductible applies. If the DRE is done in a hospital outpatient setting, there is a copayment.

Medicaid coverage

Medicaid coverage of prostate cancer screening varies by state.

People who qualify for Medicaid based on their state’s decision to expand Medicaid under the Affordable Care Act (ACA) are entitled to the same screening services as people covered by private insurance.

For people who qualify for Medicaid based on other pathways, prostate cancer screening coverage is determined by the state. Most Medicaid programs do cover screening.

To learn more about prostate cancer screening coverage in your state, contact your state’s Medicaid office.