Elevated PSA

Disease Description (Causes and Symptoms)

• Definition and pathophysiology: The prostate is part of the male reproductive system, surrounds the urethra, and produces part of the semen. It is a condition in which a malignant tumor develops due to abnormal proliferation of prostate cells, most of which are stimulated to grow by androgens (male hormones). In the early stages, it remains localized, but as it progresses, it may invade the prostate capsule or metastasize to distant sites such as the lymph nodes, bones, liver, and lungs.
• Main causes (risk factors): The exact cause is unknown, but it is associated with older age, a family history (prostate cancer in a first-degree relative), African ancestry, obesity, and a high-fat diet.
• Main symptoms: It is often asymptomatic in the early stages. Urinary problems caused by urethral compression (frequent urination, a feeling of incomplete emptying, nocturia, difficulty urinating, and urinary retention), hematuria, and discomfort after urination may occur. With cancer progression and metastasis, bone pain (bone metastases), enlarged lymph nodes, weight loss, and general weakness may occur.

Treatment Methods

• General principles: Individualized treatment is selected according to the stage (localized vs. locally advanced vs. metastatic), tumor grade (pathological Gleason score/ISUP grade, etc.), and the patient's age, functional status, and comorbidities.
• Localized, low-risk disease (residual or microscopic lesions, etc.)
  • Active surveillance: In low-risk disease, the course is monitored through observation and regular testing (PSA, digital rectal examination, repeat biopsy, etc.).
  • Definitive treatment: Radical prostatectomy (open, laparoscopic, or robot-assisted surgery) or radiation therapy (external-beam radiation therapy or brachytherapy). The choice is determined according to the expected side effects (such as urinary incontinence and erectile dysfunction) and the patient's preferences.
• Locally advanced or high-risk disease
  • Definitive treatment (surgery/radiation) is often combined with adjuvant androgen-deprivation (hormonal) therapy (ADT).
• Metastatic disease
  • Androgen-deprivation therapy (ADT; chemical castration [LHRH agonists/antagonists] or surgical castration [oophorectomy is not applicable; in men, bilateral orchiectomy]): As the basic treatment for prostate cancer, it suppresses cancer growth.
  • In the hormone-sensitive metastatic stage, medications that prolong survival may be added to ADT, including docetaxel (chemotherapy), abiraterone, and antiandrogens such as enzalutamide.
  • In castration-resistant prostate cancer (CRPC, endocrine-resistant disease), newer hormonal agents in this class (e.g., enzalutamide and abiraterone), taxane-based chemotherapy (docetaxel and cabazitaxel), and targeted or immunotherapy (depending on the indication) may be considered.
  • When bone metastases are present, bone-modifying agents (mainly intravenous bisphosphonates: zoledronic acid) or denosumab may be used to control pain and prevent skeletal-related events.
• Palliative treatment: Radiation to relieve pain from bone metastases, catheter insertion or procedures to improve urination in cases of urinary retention, and other treatments.
• Lifestyle management and supportive measures: Management of sexual function and urinary symptoms (pelvic floor muscle strengthening and a voiding diary), calcium and vitamin D intake and weight-bearing exercise to prevent osteoporosis, and management of the risks of metabolic syndrome and bone loss during ADT (monitoring blood glucose, lipids, and bone density).
• Precautions (risk of complications and self-management)
  • ADT: Decreased libido, hot flashes and weight gain, osteoporosis, muscle loss, and metabolic abnormalities (insulin resistance and hyperlipidemia).
  • Surgery: Urinary incontinence, erectile dysfunction, and complications related to surgery and anesthesia.
  • Radiation: Irritative symptoms of the rectum and bladder (frequent urination and hematuria), with the possibility of rectal injury.
  • Chemotherapy: Bone marrow suppression (anemia and risk of infection), nausea and vomiting, fatigue, and others.
  • Complications of bone metastases: Pain, pathological fractures, and spinal cord compression (requiring emergency treatment).
  • Self-management: Regular bone-density testing and exercise, smoking cessation, weight control, and adherence to regular testing (PSA monitoring).

Checklist Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Items to bring
  • A list of all currently taken medications (including prescription drugs, over-the-counter drugs, and supplements)
  • Previous test results: Recent and past PSA levels (the trend), prostate tissue biopsy results (pathology report), digital rectal examination findings, and copies of previous prostate MRI, CT, bone scan, and PSMA PET results
  • Symptom records: Urinary symptoms (frequency, feeling of incomplete emptying, and whether urinary retention has occurred), presence or absence of hematuria, location, intensity, and timing of bone pain, fever, weight changes, and other symptoms
  • Family history (prostate, breast, ovarian, and other cancers) and allergy records
  • History of previous surgery and anesthesia
• Things to check before the visit
  • Date and level of the most recent PSA test (the trend over multiple time points is important)
  • Urinary and sexual function status (baseline information)
  • Whether symptoms of urethral or urinary tract infection are present
• Important information to tell the doctor first during the visit
  • Immediately report acute difficulty urinating (urinary retention) or severe bone pain (suspected fracture or spinal cord compression)
  • Whether you are taking anticoagulants (important before surgery or biopsy)
• Example questions (topics for the patient to ask the doctor)
  • "What is the meaning of this test? What could be causing the elevated PSA?"
  • "Based on the stage and grade, what treatment options are available, and what are their advantages and disadvantages?"
  • "What are the side effects of each treatment, and how will they affect daily life?"
  • "What is the target PSA level after treatment, and what is the follow-up testing schedule?"
  • "If there are bone metastases, how will pain be managed and skeletal-related events prevented?"

Examples of Disease-Specific Questions (1–2)

• "Considering my PSA, pathological findings (Gleason score/ISUP grade, etc.), and imaging findings together, is active surveillance or definitive treatment recommended? What is the expected long-term prognosis with each option?"
• "If I start androgen-deprivation therapy (ADT), do I need specific tests or treatments to prevent osteoporosis and metabolic abnormalities (e.g., bone-density measurement, calcium and vitamin D, and recommendations for bone resorption inhibitors)? If so, how often should they be performed?"

(Note: Decisions regarding diagnosis and treatment require individualized judgment that takes into account the stage, pathology, overall health, and patient preferences. Specific treatment should be discussed with the treating physician.)