Elevated PSA and low Free PSA with benign biopsies

  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

[Mandy2008]

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[vahiker]

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