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Dear Dr. Roach: I am 68 years old and have an enlarged prostate and benign prostatic hyperplasia (BPH). I've been taking tamsulosin for about seven years. My PSA level has slowly creeped up and was recently measured at 4.5 ng/mL. My doctor did a 4Kscore test, and it was rather high at 49%, indicating a higher potential for aggressive prostate cancer. The digital rectal exam (DRE) was normal. An MRI came out low, at PI-RADS score of 2.
My doctor indicated that there has been limited research on correlations between a relatively low PSA level and a high 4Kscore. A biopsy isn't ideal (I'm on warfarin), and it's of course invasive. My options appear to be continuing to monitor the PSA periodically or doing the biopsy. We're both leaning toward the former.
However, I think there are a number of other tests that could be done, such as a Prostate Health Index (phi) test or perhaps others. Would I benefit from taking a different test, or should we stick with the quarterly PSA test? -- G.V.
Answer: The concern is that you might have prostate cancer. A PSA of 4.5 ng/mL is moderately elevated, which increases your risk. Although the news from the MRI is good, approximately 9% of men with a PI-RADS score of 2 have significant cancer.
However, it's the 4Kscore test results that are the most concerning. A 4Kscore result of 49% means that 49% of men with this result have clinically significant cancer. Combining lab results to come up with a single score isn't always easy.
There are additional tests that could help give you more information. A phi test uses free PSA and proPSA, both of which provide additional information than a total PSA, to give another risk estimate. A PSA density test adjusts the PSA level for the size of the prostate. Your urologist should have enough information to calculate these results.
With the information you have, the very high 4Kscore test has a greater effect on your prostate risk than the MRI. So, in my opinion, your risk of having clinically significant prostate cancer is closer to the 49% of the 4Kscore test than the 9% of the MRI. The safest thing to do here is to perform the biopsy, unless further information dramatically changes this risk.
In my opinion, the benefit from gaining information about your prostate health outweighs the risk of performing a prostate biopsy in a person on warfarin (most of whom can have it stopped temporarily).