Do doctors generally assume the worst based upon PSA results?

I can't believe your urologist did not do a simple DRE. The PSA and a DRE are the VERY FIRST steps to determine what (s)he thinks is going on. The DRE lets them get a sense of the size of the prostate, and if there are any "ridges" or "bumps" or other anatomical features they can discern. That is absolutely unreal that a urologist did not do the DRE. Did (s)he say "why" they are having you do a MRI-guided biopsy, when a simpler ultrasound-guided biopsy is quicker and simpler? The ultrasound "probe" is only inserted in your rectum about 2 inches. It is simple. The one BIG question that I have for you, is what is the history of prostate cancer in the men in your family? Prostate cancer tends to follow a familial occurrence pattern. My maternal grandfather had it; my maternal uncle had it, and my own father had it. I was a near-certain candidate, and sure thing...I got it diagnosed just before my 70th birthday in January 2025. I had the DaVinci robotic-assisted RP surgery in mid-April. So...
If can remember, ask your urologist why (s)he didn't do a DRE and why they elected the MRI-guided biopsy instead of the ultrasound-guided biopsy. I have never heard any advantages of using MRI-guided biopsy. Please let us all know. Good luck.

Strangely, when a urologist did a DRE on me in hospital, he wasn't sure he could feel anything, despite the fact that my PSA was in the high 60s, and the cancer had already moved to my spine. My prostate wasn't enlarged, and it looked normal in the MRI and CT scan.

I just went thru the same thing and I am 58 yrs old. My PSA was 4.3, free PSA was around 17%. Local Doc did DRE, noted one side was larger but wasn't firm. Did 2 weeks of antibiotic to rule out infection. He scheduled a MRI with and without contrast. I freaked out, all but assumed I had PC and started a thread here. Took many peoples advice and got in at Mayo in Rochester for an initial visit before my MRI. Decided to keep local MRI appointment, as Mayo was further out (like 2 months). Mayo Doc said they would be fine with local MRI and they would read the results and make their own determination as to proceeding with biopsy. I was scheduled with Dr Paris Shah, but was seen by PA Fleenor. She was excellent, put my mind at ease and was very thorough on what the steps would be if there was anything suspicious.
Just got the results from her. No lesions present, lymph nodes normal. Pirads 2 show low, clinically significant cancer is unlikely to be present. She said at this time no biopsy is needed, and to check PSA yearly.
Moral of the story is this, follow the process and don't read too much into these forums, as most people don't ever follow through when they get good results as they usually breath a sigh of relief and move on.
It's good to be pro active, and Jeff Marchi is a wealth of information here. I would listen to his advise.

@thig350
I agree with @jeffmarc, get the PSE biomarker blood test from Oxford Biodynamics. Here is a link to their web site and the PSE test page information:
https://www.94percent.com/
I agree with others about the MRI as well.

Regarding PSA, and of course everybody is different, my PSA was 10.2 and my cancer was contained and treated, no hormone treatment... while my brother, who had prostate cancer at the same time had a PSA of 6.5 and it spread rapidly.

When or if you get the biopsy, make sure to get the Decipher genomic test to show the aggressiveness level. The test uses your biopsy material:
https://decipherbio.com/

High PSA is concerning, but it is not by itself proof you have cancer. I have had very high PSA since 2013 which at one time reached 47. Five biopsies between 2013 and 2024 - the last three of which were MRI-guided - did not find cancer. However, biopsy # 6 this year identified a G 3+4 cancer.

So, what can cause high PSA other than cancer? In my case, they were the usual culprits : some times inflammation, and in other instances infections of my enlarged prostate in the form of prostatitis. MRI's are helpful when the cancer has reached detectible levels. Even before then, genomic tests like 4kscore, Select MDX, Confirm MDX, and ExosomeDX can assess a patient's probability of aggressive prostate cancer after an abnormal PSA or DRE. Over the years, even when my biopsies were negative for cancer, all these tests showed that I had an intermediate risk of getting prostate cancer. So, that is something you could explore.

@so2315 thank you (and everyone else here) for responding. To clarify, I'm scheduled for an MRI then an ultrasound guided biopsy (not an MRI biopsy).

Now that I've had some time to breathe, better understand my situation, next steps, and do some research, I'm finding there is a lot of information out there and much of it can be a bit bleak (while truly trying to not read too much into it). But, with me having an elevated PSA level of 11.7, I haven't found much info out there that would suggest its due to BPA, prostatitis, or other causes. I'd probably have to have a prostate the size of a dump truck to produce an 11.7 PSA...

The overall theme seems to be that a PSA of 11.7 is probable to be PC of some degree. Also, I've noted that some folks have had mildly elevated PSA levels and it was a problem then others who have significantly elevated PSA levels it was less of a problem. So, it comes down to case by case and each one is different. I've figured out that it's kind of hard to guesstimate until I have my aforementioned procedures completed then go from there. But I will say that for me the worst part is the waiting and biggest concern is a spread outside of the prostate.

So again, thank you all for responding.

@brianjarvis

I agree with @brianjarvis these are the steps your major hospitals & cancer centers Urologists do.

High PSA, DRE, MRI, Biopsy (best is Transperineal Fusion), PSMA Pet scan. Treatment options.....

I had 2 years above 4.0 (4.96 and 5.41) Age 63 and 64.
MRI suggested a biopsy.
Biopsy was 14 samples, six samples at 3+3 with 1 at 3+4. Just above threshold that two different urologists were comfortable with active surveillance.
I opted for the RALP.

My brother’s father-in-law died a miserable death from prostate cancer after a doctor assured him that he would die with prostate cancer rather that from prostate cancer…