@yarddogman When PSA hovers between 4.0-10.0 (gray zone) and MRI doesn’t give a definitive answer (PIRADS 3) there are other biomarkers that may help in making the (very invasive) tissue biopsy decision:

PSA Density (PSAD): The larger the prostate volume (due to an enlarged prostate), the more PSA can be produced. PSA Density is the ratio of PSA to prostate volume. A PSAD above 0.15 (or 0.2 in some studies) can increase concern for prostate cancer, while lower values are more favorable.

% Free PSA: PSA circulates in the blood in two forms – either attached to certain blood proteins or unattached (“free”). If the PSA is elevated but the % Free PSA is low (< 25%), it may indicate a higher risk of prostate cancer.

PSA Doubling Time: The number of month it takes for PSA to double. If the PSADT is < 10
months, patients tend to do worse.

PSA Velocity: The change in PSA levels over time. A rapid rise in PSA may indicate the presence of cancer or an aggressive cancer.

Liquid biopsies: Some get a liquid biopsy first, and use those results to help make the decision whether to get a tissue biopsy,
> Liquid (blood) tests: 4KScore; EpiSwitch PSE; Phi Prostate Health Index;
FoundationOne®Liquid CDx.
> Liquid (urine) tests: SelectMDx; PCa3 (PC Antigen 3); MyProstateScore (MPS),
ExoDx.

In the meantime, you can still get another Total PSA test to compare it to your most recent one (and get the “Free PSA” test done with it so that you can calculate your % Free PSA).

If still unsure, I would get the MRI-guided tissue biopsy.