[Dr Yau’s Health Insights] Does a high PSA level always mean prostate cancer? Understanding normal PSA levels, symptoms, screening tests and treatment options!

2026-10-02

8 Mins Read

What is the PSA test | Normal range for PSA
Six common reasons for an elevated PSA level
Latest approaches to investigating an abnormal PSA result
Treatment options for prostate cancer

“Does a high PSA level mean I have prostate cancer?” This is one of the most common questions asked in urology clinics. In fact, PSA (Prostate-Specific Antigen) is an important indicator of prostate health, but its level can be influenced by many different factors and is not a direct diagnostic test for cancer.

In this article, we will explore the role and limitations of PSA testing, as well as introduce some of the latest advances in prostate cancer screening and treatment. Understanding these developments can help men take a more informed and proactive approach to their prostate health.

What is the PSA test?

PSA, or Prostate-Specific Antigen, is a protein produced by cells in the prostate gland. Whether the prostate is healthy, enlarged or affected by cancer, prostate cells will produce PSA. A PSA test is a simple blood test that measures the level of PSA in the bloodstream, expressed in nanograms per millilitre (ng/mL). The result helps doctors assess the health of the prostate and remains an important blood marker used in the detection of prostate cancer.

However, it is important to remember that PSA is a clue, not a diagnosis. An elevated PSA level may indicate that something is affecting the prostate, but it does not reveal the exact cause. Further investigations are often required to determine whether the result is related to prostate cancer, benign prostate enlargement, inflammation or another condition.

What is the normal range for PSA?

There is no single PSA level that can be considered "normal" for all men. As PSA levels tend to rise naturally with age, doctors usually interpret the results based on a combination of factors, including age, prostate size and individual risk factors.

The following age-specific reference ranges are commonly used:

Age group	PSA reference range (ng/mL)
	40-49
40-49	0-2.5
	50-59
50-59	0-3.5
	60-69
60-69	0-4.5
	70 and above
70 and above	0-6.5

If a PSA level falls between 4 and 10 ng/mL, it is often considered a "grey zone". In such cases, the result should be interpreted alongside other clinical findings and risk factors, and should not be used on its own to draw conclusions.

Six common reasons for an elevated PSA level

There are many possible reasons why a PSA level may be elevated, and prostate cancer is only one of them. The following are six of the most common causes:

1. Prostate cancer

Cancer cells may produce higher levels of PSA. This is one of the key possibilities that doctors aim to rule out when PSA levels are elevated.

2. Benign prostatic hyperplasia (BPH)

This is the most common non-cancerous cause of an elevated PSA level. The prevalence of benign prostatic hyperplasia increases with age. It is estimated that around half of men over the age of 50 and the majority of men over the age of 70 experience some degree of prostate enlargement.

3. Prostatitis

Both acute and chronic inflammation of the prostate can lead to an increase in PSA levels.

4. Urinary tract infection (UTI)

PSA levels may rise temporarily, particularly when an infection affects the prostate gland.

5. Recent ejaculation

Ejaculation within 48 hours before the test may cause a temporary increase in PSA levels.

6. Prostate stimulation

Activities or procedures that irritate or stimulate the prostate, such as a digital rectal examination (DRE), urinary catheterisation, cystoscopy or even prolonged cycling, may cause PSA levels to rise temporarily.

PSA is highly sensitive to changes in prostate tissue, but it is not 100% specific for prostate cancer. An elevated PSA level can be caused by a variety of benign conditions and should not be automatically interpreted as a sign of cancer.

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Latest approaches to investigating an abnormal PSA result

If a PSA result is abnormal, doctors will usually investigate further in a stepwise manner.

Step 1: Risk assessment

Doctors will consider a range of factors, including the patient's age, prostate size, PSA velocity (how quickly the PSA level changes over time), and the ratio of free PSA to total PSA. One useful measure is PSA density, which is calculated by dividing the PSA level by the prostate volume. This may help distinguish whether an elevated PSA level is due to a larger prostate gland or a potential abnormality within the prostate.

Step 2: Digital rectal examination (DRE)
During a digital rectal examination (DRE), the doctor assesses the size, shape and consistency of the prostate and checks for any abnormal lumps or areas of hardness. Although simple, this remains an important clinical examination.

Step 3: Imaging investigations

Multiparametric MRI (mpMRI): Used to identify suspicious areas within the prostate and is currently one of the most commonly used imaging tools in prostate cancer assessment.
Micro-ultrasound: An emerging technology that provides higher-resolution imaging of the prostate. While it has not completely replaced mpMRI, it is increasingly being used in some centres for prostate cancer risk assessment and biopsy guidance

Step 4: Prostate biopsy (if required)

If imaging identifies a suspicious lesion, a prostate biopsy may be recommended. This involves taking tissue samples from the prostate for pathological examination and remains the gold standard for diagnosing prostate cancer.

Current guidelines recommend combining targeted biopsy with systematic biopsy to improve diagnostic accuracy.

Step 5: PSMA PET scan

A PSMA PET scan is currently the most sensitive imaging technique for detecting metastatic disease and is used to assess whether prostate cancer has spread to other parts of the body.

One important point should be emphasised: while PSA remains a valuable screening tool, a small proportion of men with prostate cancer may still have PSA levels within the normal range. For this reason, PSA results alone cannot completely rule out the possibility of prostate cancer. Regular screening and a comprehensive assessment remain the most reliable approach.

Treatment options for benign prostatic hyperplasia (BPH): From medication to newer technologies

The treatment of benign prostatic hyperplasia (BPH) is rarely a one-size-fits-all approach. Instead, treatment is tailored according to the severity of symptoms, prostate size, age and overall health of the patient.

Mild to moderate symptoms: Medication as the first-line approach

For patients with milder symptoms that do not significantly affect daily life, medication is often the initial treatment option. The most commonly prescribed medications fall into two main categories:

Medications that relax the muscles around the urinary tract (α-blockers): These drugs help relax the smooth muscles of the prostate and bladder neck, allowing urine to flow more easily. They generally work quickly, but may cause side effects such as dizziness or low blood pressure.
Medications that reduce prostate size (5α-reductase inhibitors): These medications help shrink the prostate by targeting the underlying hormonal mechanisms that contribute to prostate enlargement. However, they may take several months to produce noticeable results, and some patients may experience sexual side effects.

The main advantages of medication are that it is non-invasive and convenient. However, long-term treatment is often required, and potential side effects may discourage some patients from continuing therapy.

Moderate to severe symptoms: Considering surgical intervention

When medication is no longer effective, or when patients prefer not to remain on long-term medication and wish to pursue a more definitive solution, surgical treatment may be considered.

Today, a variety of minimally invasive surgical options are available. These procedures are typically performed through the urethra, meaning no external incision is required. As a result, the risk of bleeding and recovery time are generally much lower than with traditional open surgery.

Traditional standard surgery: Transurethral Resection of the Prostate (TURP)

This is the most established and widely used surgical treatment for benign prostatic hyperplasia (BPH). During the procedure, the surgeon inserts an endoscope through the urethra and removes excess prostate tissue to relieve the obstruction and improve urine flow. The procedure is typically performed under either regional or general anaesthesia, and patients usually require a hospital stay of three to four days afterwards. While TURP is highly effective, it is a more invasive procedure and is associated with a relatively higher risk of bleeding.¹

A newer option: Rezūm Water Vapour Therapy

For patients with a prostate volume of approximately 30 to 80 cc who prefer a less invasive approach, Rezūm Water Vapour Therapy may offer an alternative treatment option. This minimally invasive procedure involves inserting a fine needle into the prostate through the urethra and delivering water vapour at approximately 103°C. Each treatment lasts around nine seconds. The heat causes excess prostate cells to break down naturally, after which they are gradually absorbed by the body. As the prostate shrinks, the urethra becomes less obstructed, helping to improve urinary flow.²

One of the main advantages of Rezūm is its minimally invasive nature. The procedure is typically performed under sedation, and patients can often return home within a few hours. Improvements in urinary symptoms usually begin to appear within one month, with more significant benefits seen over the following three months. Because no tissue is surgically removed, the risk of bleeding is very low, and sexual function can often be better preserved compared with more invasive procedures². However, Rezūm is not suitable for all patients. Some individuals may still need a temporary urinary catheter after treatment, and symptom improvement is usually gradual, developing over several weeks to months rather than immediately after the procedure. In recent years, Rezūm has become available at selected healthcare institutions in Hong Kong and Chinese mainland, providing an additional minimally invasive treatment option for suitable patients with benign prostatic hyperplasia. Patients can explore the treatment options available in both locations based on their condition, their doctor's advice and their individual needs.

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Treatment options for prostate cancer³

If PSA testing, imaging scans and a prostate biopsy ultimately confirm a diagnosis of prostate cancer, it is understandably worrying news. However, it is important to remember that prostate cancer is one of the cancers for which a range of treatment options is available, and in some cases it progresses relatively slowly. When detected early, treatment outcomes are generally very favourable.

1. Active surveillance (for low-risk patients)

Active surveillance may be suitable for low-risk, slow-growing prostate cancers. Patients undergo regular PSA testing and imaging assessments, with treatment initiated only if there are signs of disease progression. This approach helps avoid unnecessary treatment and its potential side effects.

2. Surgery (radical prostatectomy)

Surgery is one of the main treatment options for localised prostate cancer. Surgical techniques have evolved from traditional open surgery to minimally invasive laparoscopic surgery and, more recently, robot-assisted procedures such as da Vinci robotic surgery. Robot-assisted surgery is generally associated with smaller incisions and a faster recovery.

3. Radiotherapy

Radiotherapy options include external beam radiotherapy and brachytherapy (internal radiotherapy). These treatments may be suitable for patients who are not suitable candidates for surgery or who prefer not to undergo an operation.

4. Hormone therapy (androgen deprivation therapy)

Hormone therapy works by reducing the levels of male hormones (androgens) that can stimulate the growth of prostate cancer cells. It is commonly used in patients with advanced or recurrent prostate cancer.

5. Other treatment options

Other available treatments may include:

Cryoablation
High-intensity focused ultrasound (HIFU)
Chemotherapy
Immunotherapy
Targeted therapy
Radioligand therapy (such as Lu-PSMA)

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Screening recommendations for prostate cancer

According to cancer statistics in Hong Kong, prostate cancer is one of the most common cancers among men, with incidence rates continuing to rise in recent years. When detected at an early stage, prostate cancer generally has an excellent prognosis, with five-year survival rates exceeding 98% for Stage I and Stage II disease.⁴ Regular screening and early detection remain key to achieving the best possible treatment outcomes.

Screening is generally recommended for:

Men at average risk: Discuss PSA testing and a digital rectal examination (DRE) with a doctor from the age of 50.
Men at higher risk (including those with a family history of prostate cancer): Consider screening from the age of 40 to 45.

A raised PSA level does not necessarily mean prostate cancer is present. Rather, it serves as a signal that further attention should be paid to prostate health. If an abnormal result is detected, delaying or avoiding follow-up assessment is often the worst course of action.

Men aged 50 and above should consider regular PSA testing, while those with a family history of prostate cancer may benefit from earlier screening. When prostate cancer is detected at an early stage, treatment outcomes are often highly favourable and survival rates are generally high. Ultimately, taking an active role in your health remains one of the most important steps you can take.

The above content is reviewed by Dr Yau - Chief Medical Officer of AXA Hong Kong and Macau.

Information and materials provided is general in nature and does not constitute medical or health advice from AXA Hong Kong and is on an “as is” and “as-available” basis without representation and/or warranty of any kind, either express or implied. While AXA Hong Kong has taken reasonable care in providing such information and materials, they are not specific to your investment objective, financial situation, health or medical conditions or particular needs. No warranty or responsibility is assumed by AXA Hong Kong and our related or holding companies regarding non-infringement, security, accuracy, completeness, adequacy, reasonableness, fitness for a purpose or free from computer viruses in connection with the information and materials provided. AXA Hong Kong and our related companies and holding companies do not accept any liability for any loss, damage, cost or other expense, whether wholly or partially, directly or indirectly, arising from any error, inaccuracy or omission of the information and materials to the extent that such liability is not excluded by law.

Reference:

CUHK Medical Centre. (n.d.). Innovations in Benign Prostatic Hyperplasia (BPH) Surgery. Health Corner, CUHK Medical Centre. Retrieved from https://www.cuhkmc.hk/health-corner/prostate-health/benign-prostatic-hyperplasia/innovations-in-benign-prostatic-hyperplasia-bph-surgery
HKU Clinical Oncology Centre. (n.d.). New Trends in Minimally Invasive Treatment for Benign Prostatic Hyperplasia. HKU Clinical Oncology Centre. Retrieved from https://hkuoc.hk/en/%e5%89%8d%e5%88%97%e8%85%ba%e5%a2%9e%e7%94%9f%e5%be%ae%e5%89%b5%e6%b2%bb%e7%99%82%e6%96%b0%e8%b6%a8%e5%8b%a2/
Centre for Health Protection. (n.d.). Prostate Cancer. Department of Health, The Government of the Hong Kong Special Administrative Region. Retrieved from https://www.chp.gov.hk/en/static/80055.html
CUHK Medical Centre. (2026, June 16). Does an Elevated PSA Level Mean Prostate Cancer? (AM730 column article). CUHK Medical Centre. Retrieved from https://www.cuhkmc.hk/tc/article/article/CUHKMC_AM730_NHY_20260616 (Chinese only)

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