Elevated levels of PSA (>4 ng ml-1) occur in about 53% of men with intracapsular microscopic and 77% of men with intracapsular macroscopic prostatic cancer, but can also occur in 30-50% of men with benign prostatic hypertrophy (BPH). A combination of PSA and digital rectal examination, followed by prostatic ultrasound in patients with abnormal findings, is commonly used for screening in US but is not recommended in the UK. As yet, there is no definite evidence of survival benefit from screen detection of early prostate cancer. About 40% of patients with PSA levels of 4.0-9.9 ng ml-1 at screening will already have tumour spread outside the prostate.
The ratio of free to total PSA is being used to improve diagnostic specificity—more of the PSA is protein-bound in patients with prostate cancer compared with BPH. The ratio of free to total PSA is low (about 10%) in prostate cancer compared to >16% in BPH and prostatitis. Bone or lymph node metastases are usually, but not always, associated with an elevated PSA.
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