What does a fluctuating PSA mean?

I am 59 years old and have a fluctuating PSA. In 2005, it was 2.5 ng/ml. A 12-core biopsy was negative. In 2006, my PSA dropped to 0.97 ng/ml. In 2007, it went up to 2.54, and I had another biopsy. All 14 cores were negative for cancer. What does this mean for my prostate health?

Kevin Loughlin, M.D., M.B.A., director of Urologic Research at Brigham and Women’s Hospital, responds:

Variations in PSA like yours aren’t particularly remarkable. In fact, fluctuations in PSA of up to 36% from one day to the next may have nothing to do with cancer. Prostate infections and inflammation may account for some of the variation, as can an enlarged prostate and advancing age. However, the Prostate Cancer Prevention Trial found that prostate cancer might be detected in 23.9% of patients with a PSA of 2.1 to 3 ng/ml, so you don’t want to ignore an elevated PSA either.

Before you have a third biopsy, consider having your free PSA measured.  A 2008 study of 125 men who had a prostate biopsy showed that the percentage of free PSA in men with a total PSA of 2.5 ng/ml or less could indicate who was most likely to have prostate cancer: 59% of the men with a free PSA of 14% or less had prostate cancer versus just 13% of the men with a free PSA of 28% or more. So the lower your percentage of free PSA, the more you might want to think about having another biopsy.

You could also ask about having an endorectal MRI. This imaging test can help physicians spot abnormalities in regions of the prostate not typically sampled during a biopsy. Any follow-up biopsies could then target those suspicious areas.

Assuming the endorectal MRI and your digital rectal examination (DRE) are normal, and depending on your general health and any medications you take, you and your doctor might simply want to track your PSA over time. If it jumps much above its current level, you could opt for a biopsy then.

Unfortunately, there is no one right answer to your question. In the end, it comes down to combining all of the data you have, talking with your doctor, and making an educated decision about what to do next.

SOURCES: Lawrentschuk N, Fleshner N. The Role of Magnetic Resonance Imaging in Targeting Prostate Cancer in Patients with Previous Negative Biopsies and Elevated Prostate-Specific Antigen Levels. BJU International 2009;103:730–33. PMID: 19154475.

Walz J, Haese A, Scattoni V, et al. Percent Free Prostate-Specific Antigen (PSA) Is an Accurate Predictor of Prostate Cancer Risk in Men with Serum PSA 2.5 ng/ml and Lower. Cancer 2008;113:2695–703. PMID: 18853417.

Originally published November 2009; last reviewed March 16, 2011.

Miranda Hinds

A friend was treated with testosterone therapy…whether or not he had an enlarged prostate prior is unknown. Nevertheless, he had prostate surgery March of ’13, with a very long healing process. This is a 59 year old very active, very athletic male. He continues to take 1/2 cc of testosterone a week (injection). In Feb. 2014 his PSA level was 5.5 ng/ml..On 5/12 a PSA was performed with a result of 5.7ng/ml.. On 5/22 his urologist ordered another PSA with a free PSA…results 8.5 ng/mg and a free PSA of .77 ng/ml or 9.1% in 10 days…The methodology used Was ECLIA. The Urologist is insisting on a biopsy. What are the other alternatives…and wouldn’t the hormonal treatment affect the PSA results. What would be your recommendation? a repeat, perhaps?

jonathan honig

It is hard to believe that with all the billions spent on medical research no one has done any research on patterns over five years of psa and free psa in people with prostate cancer. This is beyond belief.


I have a PSA free % of 36%. PSA of 12. Free PSA 4.3…I will undergo biopsy after a few days. I am a heart patient. Could you suggest if it is cancer or a benign disease?


Insist on a multi-parametric MRI scan which concentrates specifically on the prostate gland and close organs.. My partner had an exam done by his GP…gland normal size although slightly firm..psa 4.5. GP recommended a biopsy via NHS but as this procedure would distort a future image of the gland for scan purposes we declined. Decided on a private consultancy…much more thorough exam of the prostate done by the consultant…prostate enlarged and two bumps found! Recommended m.p. MRI as above (cost £700). Result within 3 days..benign hyperplasia..continue to monitor psa every 3 months..further checks if psa rises by more than 1.0 over a 12 month period. My partner is 54 and his father had prostate cancer so he was under great pressure to have a biopsy done – without an MRI in my opinion, it would be looking for a needle in a hay stack.

I understand there has recently been a change of thinking in the NHS in that they no longer just go for a biopsy but think more about MRI and f necessary any identified possible tumour areas can be targeted for biopsy. Wish this policy had been adopted much earlier. Hope this helps someone…Carol

Eric Olsen

It means some quack wanted to turn your prostate into a sponge. I hope you didn’t have any side effects from two biopsies performed when your PSA was in normal 0-4 range. It’s infuriating.

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