If you or someone you're close to has prostate cancer, you'll hear a lot about the PSA blood test and the PSA doubling time (PSADT).PSA helps medical providers screen for and diagnose prostate cancer at an early stage.
But there's more to the test than just that. The PSADT—a measurement of how quickly the PSA is increasing—is especially important after you've been treated for prostate cancer.
This article will walk you through why the PSA doubling time is so significant, how your doctors will use it to monitor for recurrence, and what factors will play a role in how a recurrence is treated.
What is PSA?
PSA stands for prostate-specific antigen. It's a protein produced by cells in the prostate gland. The PSA test measures levels of this protein in the blood. High levels can be a sign of prostate cancer.
Why PSA Is Important
PSA plays many different roles. The most common is determining prostate cancer risk.
|PSA Levels and Prostate Cancer Risk|
PSA is also used to help determine the stage of a newly diagnosed prostate cancer. Staging is a measurement of how advanced the disease is.
The PSA doubling time can also detect a relapse of cancer after treatment with surgery or radiation.
The time it takes for PSA blood levels to double gives your medical team an insight into how aggressive your prostate cancer will be in the future.
That can guide your treatment plan, which may include:
- Testosterone deprivation therapy with Lupron Depot (leuprolide acetate)
The PSA and PSADT are important for prostate cancer screening, diagnosis, and—in the case of a relapse—determining the best treatment plan.
Prostate Cancer Staging, Grading, and Risk
Detecting a Relapse
PSA is useful for detecting a relapse of prostate cancer after surgery or radiation.After prostate cancer surgery, PSA is normally undetectable, and even small rises could point to a recurrence.
Aftercurative radiation, the PSA generally stays under 1.0 long-term.However, there are exceptions. Sometimes, the PSA level drops slowly after radiation and it may take years to reach its lowest point.
Younger people may have a short-term PSA rise that's not cancer-related. That's more common after the seed-implant type of radiation. This temporary rise is called a "PSA bump" or "bounce." It can develop between one and four years after treatment.
It may be linked with anti-cancer activity in the immune system, which is a good thing. However, it's sometimes mistaken for a recurrence, which can lead to fear, stress, and even unnecessary hormone therapy.
Treatments for Prostate Cancer
What Guides Treatment
When cancer comes back, the PSADT is an indicator of how fast it's growing.
Ultimately, relapse treatment is guided by:
- The PSADT
- Your original (pre-treatment) risk category
- The tumor's location
- Whether you originally had surgery or radiation
Your age, other illnesses, and overall health will also be considered.
The PSA doubling time has a big influence on treatment.There are treatments for men whose prostate cancer had recurred and is getting worse despite anti-hormonal treatment with Lupron Depot.
Treatments for recurrence of prostate cancer that hasn't spread:
- PSADT of 10+ months: Observation is generally preferred. Secondary hormone therapy can be considered.
- PSADT of three to 10 months: Treatment with Erleada (apalutamide), Nubeqa (darolutamide), or Xtandi (enzalutamide) is preferred. Additional secondary hormone therapy is also recommended.
- PSADT of three months or less: Treatment should be aggressive, such as six cycles of Taxotere (docetaxel) along with Lupron Depot. Some medical providers may consider new drugs like Zytiga (abiraterone acetate), Xtandi, or Orgovyx (relugolix).
Original Risk Category
Your original risk category will also play a role in treatment decisions.
- Low risk: Cancer is confined to the prostate, PSA is less than 10 and grade group 1, or the tumor is very slow-growing.
- Intermediate risk: Cancer is confined to the prostate, PSA is between 10 and 20, or grade group 2 or 3.
- High risk: Cancer extends outside the prostate, PSA is higher than 20, or grade group 4 o r 5; or the tumor is very aggressive and has spread to other areas.
The higher the risk, the more aggressive the treatment. For example, if you were originally low risk, your treatment may include either cryotherapy, radiation, or Lupron Depot alone if cancer is confined to the prostate (after radiation) or the prostatic bed (after prior surgery).
If you were originally in the high-risk category, treatment may mean Lupron Depot plus pelvic lymph node radiation.
After surgery or radiation, medical providers watch for a cancer relapse with PSA and PSADT test results. Those numbers plus your original risk category are considered together when deciding what treatment course to follow—the faster the PSADT and the higher your risk category, the more aggressive treatment will be.
If you have a rising PSA after surgery or radiation, your doctor will likely order imaging studies to find the location of your cancer recurrence.
Common scans are:
- PET scans using axumin, C11 acetate, or choline
- Color Doppler ultrasound or 3D MRI techniques to spot residual cancer.
- Pelvic MRI or CT scans can show spreading to pelvic lymph nodes.
- New F18 PET bone scans can detect much smaller cancers than older types.
Cancer in the prostate or prostate bed is considered a local recurrence. Cancer that's spread outside of that area is called metastatic.
Treatment of metastatic recurrence depends on where it is and many other factors.
With a local relapse, disease suppression with Lupron Depot is an option.
That's especially true if you have a:
- High PSA
- Short PSADT
- Otherwise long life expectancy
Lupron Depot alone is almost never a cure, but it often controls the disease for more than a decade.
Some of the newer, more accurate PET scans may not be covered by your insurance. Be sure to check on your coverage before you opt for one of these expensive tests.
What to Expect During a PET Scan
Generally, if you were low-risk orintermediate-riskbefore surgery and develop a PSADT of between six and 12 months, your recurrence has a good chance of being cured with radiation treatment to the prostate bed.
Radiation is most effective when the PSA level is low and the PSADT is long without evidence of spread/metastases on imaging studies.
If you want to avoid radiation side effects, another option is to suppress the PSA with an intermittent, six-month course of Lupron Depot.
If your PSA doubling time is faster—for example, under six months—your medical provider is likely to recommend pelvic-node radiation plus Lupron Depot for as long as 12 to 18 months.
If you were high-risk before surgery, treatment will often be node radiation with12 to 18 months of Lupron Depot.Your medical provider may suggest adding more powerful drugs like Zytiga, Xtandi, or Taxotere.
For a rising PSA after radiation, a popular approach is cryosurgery (freezing cancer cells).Newer scans help the cryosurgeon focus on cancerous areas, rather than treating the whole prostate.
This is called focalcryotherapy. It offers much fewer side effects than freezing or removing the whole gland.
Another alternative is prompt treatment with Lupron Depot. This can suppress the local disease.
It's considered reasonable when:
- The PSADT is longer than six months
- The original risk category was eitherloworintermediate
If you were originally high risk, a local relapse should be treated aggressively with cryosurgery or seed implantation. Lupron Depot alone is less likely to work.
The prostate is rarely removed after radiation, due to high rates of incontinence and erectile dysfunction.
Oncologists and other medical providers use multiple scans, including some newer types, to find where cancer has recurred. Once it's located and there is no evidence of metastases, the PSA, PSADT, original risk category, and other factors are used to determine treatment.
Treatment courses depend largely on whether your original cancer was treated with surgery or radiation.
- After surgery, radiation and Lupron Depot are options.
- After radiation, cryotherapy or Lupron Depot are common choices.
- Lupron Depot alone is recommended when PSA and PSADT indicate more aggressive cancer.
Deciding on a treatment for a PSA relapse is complex.The choice is based on factors including your original risk category, PSA doubling time, and scan findings.The location ofrecurrent cancer may remain uncertain, even with the best scans.
Treatment with cryosurgery or radiation alone is reasonable when:
- Scans indicate that cancer hasn't spread to the nodes.
- The previous risk category was low or moderate.
- The PSADT is long.
Microscopicmetastases in the pelvic nodes don't always show up on scans.
They're more likely if:
- The PSADT is fast.
- The previous risk category was high.
In these situations, pelvic lymph node radiation plus an extended course of Lupron Depot is usually recommended.
A Word From Verywell
Cancer is always serious, but the overall outlook of prostate cancer is often positive.Most people with prostate cancer have a good 15-year prognosis.
Sometimes, prostate cancer can be cured. Even when it's not, it can be controlled for years and even decades.
Keep up with your monitoring tests, including the PSA doubling time, is a key component of staying well in the long term.
Prostate Cancer Causes and Risk Factors
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
National Institutes of Health, U.S. National Library of Medicine: MedlinePlus. Prostate-specific antigen (PSA) test.
National Institutes of Health, National Cancer Institute. Prostate-specific antigen (PSA) test.
National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology (NCCN guidelines): Prostate cancer, version 2.2021.
Kishan AU. PSA bounce, prognosis, and clues to the radiation response.Prostate Cancer Prostatic Dis. 2021;10.1038/s41391-021-00387-4. doi:10.1038/s41391-021-00387-4
Schweizer MT, Huang P, Kattan MW, et al. Adjuvant leuprolide with or without docetaxel in patients with high-risk prostate cancer after radical prostatectomy (TAX-3501): important lessons for future trials.Cancer. 2013;119(20):3610-3618. doi:10.1002/cncr.28270
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Kitajima K, Murphy RC, Nathan MA, et al. Detection of recurrent prostate cancer after radical prostatectomy: comparison of 11C-choline PET/CT with pelvic multiparametric MR imaging with endorectal coil.J Nucl Med. 2014;55(2):223-232. doi:10.2967/jnumed.113.123018
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By Mark Scholz, MD
Mark Scholz, MD, is a board-certified oncologist and expert on prostate cancer.
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The risk of prostate cancer death within five-years of relapse was 50% for patients with a PSA doubling time of 12 months or less compared to 10% for patients with a doubling time greater than 12 months. Other authors have clearly demonstrated that PSA doubling time adds information to other available predictors.
Some evidence shows that faster-rising PSA levels may be a sign of cancer. Men who have a PSA level that doubles within a 3-month period tend to have a worse prognosis (outlook) compared to men whose PSA level does not double. This is also known as PSA doubling time.
A blood PSA level of 2.1 nanograms per milliliter (ng/mL) of blood is still in the normal range for a man your age. But the rapid increase in your PSA level is concerning and does merit some follow-up. A PSA increase of . 75 or more in a year has been shown to be associated with prostate cancer.
Following a prostatectomy, the most widely accepted definition of a recurrence is a confirmed PSA level of 0.2 ng/mL or higher. After radiation therapy, the most widely accepted definition is a PSA that rises from the lowest level (nadir) by 2.0 ng/mL or more.
With a biochemical recurrence within 3 years of prostatectomy, a PSA doubling time of ≥ 15 months, and a pathology finding of Gleason score ≤ 8, the nomogram of Freedland et al indicates that he has an estimated cancer-specific survival of 99% at 5 years, 93% at 10 years, and 81% at 15 years.
PSA levels under 4 ng/ml are generally considered normal, while levels over 4 ng/ml are considered abnormal. PSA levels between 4 and 10 ng/ml indicate a risk of prostate cancer higher than normal. When the PSA level is above 10 ng/ml, risk of prostate cancer is much higher.
Besides cancer, other conditions that can raise PSA levels include an enlarged prostate (also known as benign prostatic hyperplasia or BPH ) and an inflamed or infected prostate (prostatitis). Also, PSA levels normally increase with age.
In the overall study population, the mean change in PSA levels was 2.9% per year and the rate of change in PSA increased modestly with age (P < . 001). Overall, men who developed prostate cancer experienced a more rapid percent change in PSA per year than men who did not (P < . 001).
Any prostate stimulation can trigger the release of extra PSA. This can include ejaculation and vigorous exercise, especially bike riding – but even having a DRE can raise PSA levels. For this reason, doctors usually draw blood before performing the DRE to avoid affecting the PSA test results.
The normal range is between 1.0 and 1.5 ng/ml. An abnormal rise: A PSA score may also be considered abnormal if it rises a certain amount in a single year. For example, if your score rises more than 0.35 ng/ml in a single year, your doctor may recommend further testing.
Although you've had treatment aimed at getting rid of your prostate cancer, your doctor or nurse won't usually use the word 'cure'. Instead they may say you're 'in remission'. This means there is no sign of cancer. Unfortunately, your doctor or nurse can't say for certain whether your cancer will come back.
Fortunately the five year survival rate for men with localized prostate cancer is nearly 100 percent. However, up to 40 percent of men will experience a recurrence, so it is important to understand your risk for recurrence.
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After surgery to remove your prostate (prostatectomy)
If your PSA level starts to rise, this might mean the cancer has come back. Your doctor might recommend: radiotherapy to where the prostate was. hormone treatment.
We can definitely correlate post-treatment relapses with pretreatment PSA velocity, or how quickly the PSA rises. We did a study showing that a pretreatment PSA that increased by more than 2 ng/ml in a year is the strongest predictor that the PSA will double in less than three months after surgery.
Remaining prostate tissue might continue to grow, leading to increased PSA levels. Inflammation of prostate tissue (prostatitis). Infection or inflammation of the prostate gland or remaining prostate tissue can cause your PSA levels to increase.
After radiation therapy it may take 1-2 years for your PSA to drop to its lowest level. Each case is different, so ask your doctor about what your numbers mean.
One hospital-based study found that higher anxiety increased PSA screening rates in men, particularly for those with a family history of PCa seeking reassurance from a normal test result.
These include: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, and naproxen. Cholesterol-lowering statins, such as Lipitor (atorvastatin) and Zocor (simvastatin) High blood pressure drugs known as thiazide diuretics.
Benign prostatic hyperplasia (BPH)
Along with the swelling, a prostate with BPH may produce more PSA than usual. Your doctor may recommend additional tests to confirm BPH.
A urinary tract infection (UTI) is an infection of the urethra or bladder that can cause PSA levels to rise.
A raised level of PSA can be a sign of a prostate condition, such as:
- enlarged prostate.
- infection or inflammation of the prostate (prostatitis)
- prostate cancer.
Patients were characterized by 3-month post-RT PSA values: <0.10 ng/mL, 0.10 to 0.49 ng/mL, and ≥0.50 ng/mL. The researchers found that a higher 3-month PSA level was strongly associated with biochemical progression-free survival (bPFS), prostate cancer-specific survival (PCSS), and overall survival (OS).