PSA relative to prostate size - anyone been told this?

In 2021 my PSA was 67.9 and the cancer had already metastasised to my spine, but my prostate was normal size on the MRI with no visible issues.

It is very frequent for someone with a large prostate to have a higher PSA. A friend of mine had a huge prostate and a PSA of 50. Multiple biopsies showed nothing. People with BPH have higher PSA’s because their prostate are usually large larger than normal. Treating them with antibiotics frequently reduces the side of the prostate and the PSA.

You could get a PSE test to find out if there is actually cancer in your body. That could eliminate the need for a biopsy.

Yes. The ratio of PSA to prostate volume is referred to as the PSA Density. PSAD helps interpret PSA levels in the context of prostate size. The PSA Density is another marker that you should be tracking while on AS.

Other markers to track while on AS are: % Free PSA, PSA Doubling Time, and PSA Velocity.

Other information helpful to know:
> What PIRADS score resulted from your MRI?
> What SUVmax scores resulted from your PSMA PET scan?
> Have you gotten a second opinion on your MRI, biopsy, and PSMA PET scan images/tissues?
>?Have you had a biomarker (genomic) test?
> Have you had a genetic (germline) test?

With a 6(3+3), let the other test numbers guide your next steps. With all those numbers and scan/test results, you’ll have a better grasp on what’s really going on

(Him saying "Something is going on with your prostate” isn’t quantifiable or testable.)

The PSA density is calculated as your PSA divided by the size of your prostate in ml. A PSAD< 0.1 is normal and a PSAD>0.15 is concerning. To feel completely safe your prostate would need to be at least 100ml in size, which is quite big.

My PSA in March was 7.8 and prostate size was 95ml
In June PSA was 4.4
In October PSA was 7.1 and Prostate volume was 70ml and MRI was downgraded to Pirads 2 from 3. So yes, as far as I know and have read, prostate size does impact PSA because a larger prostate produces more of the antigen and PSA level could also be impacted by BPH. Nonetheless my urologist would still like to do a biopsy even though there is nothing to target and my sense is that he believes there still may be something else going on.

I had a PSA of 7.7 and a prostate volume of 68. My doctor said I had a very large prostate, but the PSA was normal for that size. Although my latest MRI was negative, I decided on a second biopsy which showed cancer. I had a RP two years ago and have had a PSA of < 0.01 ever since(my 6th blood test was last week). Also, I had ZERO incontinence and my only challenge for a short time was constipation. I used a product containing Senna and it helped immensely. Hope this is helpful. Best wishes.

Ditto on the previous comments on PSA density. When my PCP felt my prostate prior to my stage IV prostate cancer diagnosis at age 51, he was not concerned because it did not feel "oversized" for my age. Still, the presence of a firm nodule prompted a PSA test (72.0) and a urology referral. My urologist measured my prostate volume at 40.3 ml, so my PSA density was 1.79. In my case, my PSA alone was enough to set off all kinds of alarm bells - but even more concerning due to the higher calculated density for my relatively "small" prostate.

What was the time between PSA tests? A rise from 11.8 to 13.8 over a short period of time should be alarming. A Gleason of 6 means that you had cancerous cells a year ago. You should develop a plan with your urologist for next steps.

@jpbossert209
Interestingly enough, the 13.8 was measured 5 days prior to the 11.8. The high number came from a different lab than my usual, and as part of a blood draw for my annual exam. Though my PSA has been steadily rising since my early 50's (am now 68), I have had dips here and there. I don't really know what to make of a 2 1/2 point rise in 3 months followed by a 2 point drop 5 days later, other than it might be lab-related. My urologist wants another TRUSP biopsy (would be 3rd in 3 years) but I have nixed that. I head south in a couple weeks and will get a 2nd opinion from my urologist in NC. If he agrees a biopsy is needed, at least I can get the trans-perineal there.

Thanks for all the feedback on PSA density...I learned something new!

@brianjarvis
Other information helpful to know:
> What PIRADS score resulted from your MRI?
I've had 2, 1st in August '24 and another in August '25. In '24 PIRADS score of 3 with one suspicious lesion in peripheral zone. In '25 no PIRADS score given, but this notation, "No MRI evidence of clinically significant prostate cancer. Previously noted PI-RADS 3 lesion in the left mid gland is no longer discretely seen."

> What SUVmax scores resulted from your PSMA PET scan?
I can find no reference to SUVmax score in my PET result. The only information that I can decipher is this, "Prostatomegaly with no focal increased uptake on a PET/CT scan." and the note "No evidence of extraprostatic disease." I looked up the former and it seems like favorable news, and the latter seems self-explanatory.

> Have you gotten a second opinion on your MRI, biopsy, and PSMA PET scan images/tissues?
Yes, New York pathology found 5 of 12 cores at 3+3 and 2 of 12 at 3+4. NC Path found nothing but 3+3, and recommended AS with 6 month PSA test and repeat biopsy after 2 years.

>?Have you had a biomarker (genomic) test?
I requested the Decipher test (based on my reading here) of my NY doc, and he ordered the GPS instead as he is familiar with it. Scored 24, likelihood of disease progression=lower. His comment was, "under 20 is great, over 40 is very bad, but in between is not particularly helpful."

> Have you had a genetic (germline) test?
Not sure if this is what you are after, but I have a family history of cancer (breast, pancreatic and bladder), with BRCA2 present in 2 of my sibs, but I have tested negative for BRCA2.

Thank you for your input!