Help with PSA reading

Hi. The PSA flag went up for me in Jan 2022 when I was pursuing REZUM therapy on visit to Urologist for my BPH.
It measured 4.54 and opened pandora's box. That is when I had first PSA Free test. Since then
1/10/22 psa total 4.54 with free 1.28 = 28%
4/19/22 5.17 1.67 = 32%
8/23/22 5.22 1.65 = 32%
1/9/23 5.5 1.55 = 28%
Another due this month.
My understanding is the higher percent of free , the better. I now see 2 urologists, one for possible REZUM and other who specializes in PC.
Not sure I can interpret your PSA total and free numbers? What are the percentages of free??PSA total looks ok to me for age. I have low confidence that anyone really knows how to interpret these numbers with certainty.
I have backburnered my REZUM plans for now. My PC urologist says not too concerned about serious PC for now..

A little more information:

Unfortunately, this Mayo web site garbled the numbers that were the table tabulating my numbers. It looked fine until I hit the SEND key.

There are/were four columns:
Date, PSA total, PSA change year to year, and % Free PSA(starting 6/17) . Maybe copy/paste could reassemble.

PSA total slowly rose for 17 yrs. BPH?
PSA velocity was steady (consistent with BPH?) until 10/18
PSA "free" wobbled around 20% (probability of cancer 20%?)

Now, you might have a problem with metrics and reference values. To begin with, the "normal ranges" or reference values that I put in the table are not well established, so, for example, the long running so called "normal range" of 4 ng/mL was poorly established but widely used, so it's easy to over-interpret the meaning of these numbers. I suspect this is so for the % Free PSA.

Now, once one starts medical procedures on the prostate such as REZUM, one will have no idea what PSA value if any to use as a reference. I gather you have not started this BPH treatment.

Have you had a diagnostic MRI of your prostate?

Interpreting MR PI-RADs is quite complicated with many variables considered by the evaluator. Let's look at the little I know, then compare your data and mine,

In one published study I looked at, a PI-RADs score of 4 and above had sensitivity of 92% for detection of high Gleason cancer (Gleason 4 or 5), although that was early work. It quickly got more sophisticated, as I noted when I look at my data.

You have one lesion identified, PI-RADS 4, and a PSA of 10.

In my case, the MRI identified a suspicious lesion, PI-RADS 4/5. My PSA was lower than yours at 6.9 (but had been rising several years).

We next went to ultrasound guided systematic biopsy, and found 10 of 13 biopsies were positive for cancer. Two were Gleason 9, and involving > 50% of the biopsy tissue. In other words, high grade, high risk disease, and lots of it.

So, when did my cancer start? Looking at longitudinal PSA, it was probably discoverable at least 5 years earlier if we were prompted by PSA tracking. I think I was lulled a little by the % free data. I doubt if those % free guidelines are well established, I should have known better

Do you happen to have some longitudinal tracking data for your PSA levels? That's the other thing I would like to see.

I'm not going any further with your data. I have no expertise in MRI. That's well beyond my pay grade. I hope my experience revealed in the data is helpful to you on your current journey.

Interpreting MR PI-RADs is quite complicated with many variables considered by the evaluator. Let's look at the little I know, then compare your data and mine,

In one published study I looked at, a PI-RADs score of 4 and above had sensitivity of 92% for detection of high Gleason cancer (Gleason 4 or 5), although that was early work. It quickly got more sophisticated, as I noted when I look at my data.

You have one lesion identified, PI-RADS 4, and a PSA of 10.

In my case, the MRI identified a suspicious lesion, PI-RADS 4/5. My PSA was lower than yours at 6.9 (but had been rising several years).

We next went to ultrasound guided systematic biopsy, and found 10 of 13 biopsies were positive for cancer. Two were Gleason 9, and involving > 50% of the biopsy tissue. In other words, high grade, high risk disease, and lots of it.

So, when did my cancer start? Looking at longitudinal PSA, it was probably discoverable at least 5 years earlier if we were prompted by PSA tracking. I think I was lulled a little by the % free data. I doubt if those % free guidelines are well established, I should have known better

Do you happen to have some longitudinal tracking data for your PSA levels? That's the other thing I would like to see.

I'm not going any further with your data. I have no expertise in MRI. That's well beyond my pay grade. I hope my experience revealed in the data is helpful to you on your current journey.

Can you elaborate on longitudinal tracking?

I discussed the PIRADS-4 with the radiologist who rated the lesion. He recommended caution in proceeding with more tests. We will see what my PC urologist says later this month. At age 81 I am proceeding cautiously.

The trending data was in that screwed up table. Here is my trending data for PSA total, Free, and % Free from my hospital database, if I can successfully post it as an attachment.

Did I have BPH? I can only say, two docs in recent years have said: "You have a very large prostate". I had some symptoms as well.

Then, when it came to the radiation of my prostate, they determined that my "large prostate" was pressed up against my colon, so they successfully separated the two by inserting a gel ,.... hydrogel I believe. The pictures were dramatic. I have had zero colorectal symptoms from the procedure. I credit the gel.

The trending data was in that screwed up table. Here is my trending data for PSA total, Free, and % Free from my hospital database, if I can successfully post it as an attachment.

Did I have BPH? I can only say, two docs in recent years have said: "You have a very large prostate". I had some symptoms as well.

Then, when it came to the radiation of my prostate, they determined that my "large prostate" was pressed up against my colon, so they successfully separated the two by inserting a gel ,.... hydrogel I believe. The pictures were dramatic. I have had zero colorectal symptoms from the procedure. I credit the gel.