Case Study #2: The "Normal" PSA That Kept Rising
This case is hypothetical — written for teaching, to help you understand how I think through decisions about elevated PSA. It is not based on any real patient.
History
Bill is a 65-year-old man who came in after his primary care doctor noticed his PSA climbing over several years. He feels well and reports no urinary symptoms. His prostate exam was normal. He is otherwise healthy and takes no daily medications.
PSA trend
2022 — 1.0 ng/mL
2023 — 1.6 ng/mL
2024 — 2.2 ng/mL
2025 — 2.8 ng/mL
October 2026 — 3.5 ng/mL
A steady climb from 1.0 to 3.5 — still inside the reference range, but more than tripled in five years.
Secondary testing
No secondary testing has been performed yet.
Previous biopsy
Bill has never had a prostate biopsy.
Family history
Bill's father had prostate cancer.
Other health considerations
None — Bill is healthy, with no conditions or medications that affect the decision.
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What I would recommend for this patient
Get a prostate MRI or a biomarker test.
Rationale
Bill's PSA is 3.5 — inside the standard reference range, a result many men would be told is 'normal.' But normal is individual, and his number has more than tripled in five years. His individual normal has clearly changed, and that change is what needs investigating, not the absolute number. His father's prostate cancer adds further reason not to dismiss the trend.
A prostate MRI is my usual first step: it assesses the probability of clinically significant cancer, measures prostate volume so we can calculate PSA density, and shows whether there's a specific area to target if a biopsy becomes necessary. A biomarker test is also appropriate — it adds an independent measure of his risk. Either path is reasonable; I tend to favor the MRI first because of the extra information it provides.
By Chad Ellimoottil, MD — urologist at Michigan Medicine specializing in prostate cancer detection.
Disclaimer: This information is for general educational purposes only and is not medical advice. Please consult a qualified healthcare professional about any medical condition, diagnosis, or treatment decision.
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