Elevated PSA and low Free PSA with benign biopsies

[Dave-S]

  I am concerned about my father's PSA levels. His PSA level has been elevating for the past three years and is now at 8.5. He also has a Free PSA level of 8. He has had biopsies on three occasions with sample sizes of 6,6,and most recently 8. All 20 have been normal. There appears to be no low level infection and the only abnormalities are several prostate calculi. My question is this. The PSA and Free PSA numbers certainly raise a red flag, yet, the number of benign biopsies
  seem to indicate no cancer. Are there other factors which could cause his PSA numbers that his urologist may be overlooking? What should be the next step in his care? Any advice on what can cause these PSA levels along with recommendations on a course of action would be greatly appreciated.
  Sincerely

  Dave S.
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Dear Dave,
It seems like you and your father have been well exposed to the elevated PSA and negative pathology on ultrasound guided prostate biopsy arena/dilemma.  The reason I say dilemma is because as urologists there is no clear cut answer as to how many ultrasound guided biopsies need to be done for progressively elevating PSA before we decide enough is enough and to call it quits.  One can conceivably perform a biopsy every 6 months (for a long time) and still not obtain any evidence for cancer.  In fact, the yield of a positive biopsy for prostate cancer is less and less as each subsequent biopsy is performed .  On one hand, one is happy not to obtain cancer, but on the other hand the question of the elevated PSA pops back up and at one point one needs to either repeat a biopsy, or ignore the elevated PSA.  As you can probably tell, it can be frustrating not only for the patient and family, but also for the physician who feels responsible to the patient.
It’s important to first realize that prostate cancer is not the only reason that a PSA test is elevated.  Other causes include a urinary tract infection, prostatitis, and BPH (enlargement of the prostate that occurs with aging).  However, prostate cancer is the most worrisome possibility and this is why an ultrasound guided prostate biopsy is performed.  As you probably know, the prostate biopsy only samples a portion of the prostate and does not tell us about whether there may or may not be cancer in the other adjacent cells which were not biopsied.  Therefore, it’s somewhat of a judgment call.
Based on the story you describe it sounds like your father may have BPH as a possible cause of an elevated PSA, although one can not say for sure.  Therefore, it is important that he still have his PSA level followed closely by his urologist and to look for any trends such as a sudden increase in the speed of increase, and to follow his/her recommendations.
Wish you the best.
This information is provided for general medical information purposes only. Please consult  your physician for diagnostic and treatment options pertaining to your specific medical condition. More individualized care is available through our department at the Henry Ford Hospital  and its suburban locations (I-800-653-6568).

Sincerely,
HFHS-M.D. J.J
*Keyword: Elevated PSA level
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