Prostate cancer is checked through a combination of blood tests, physical exams, and, if needed, imaging and biopsy. The process typically starts with a PSA blood test and may involve several follow-up steps depending on results. Most men should begin discussing screening with their doctor between ages 55 and 69, though men at higher risk may benefit from earlier conversations.
The PSA Blood Test
The PSA test measures a protein produced by the prostate gland. Higher levels of this protein in the blood can signal cancer, but they can also reflect completely benign conditions. What counts as “abnormal” depends on your age: for men in their 40s and 50s, a level above 2.5 ng/mL warrants further evaluation, while for men in their 60s, the threshold rises to 4.0 ng/mL.
Your doctor will also track how quickly your PSA changes over time. A rise of more than 0.35 ng/mL in a single year can be a red flag even if the total number is still within the normal range. This velocity matters because a stable PSA of 3.0 is very different from one that jumped from 2.0 to 3.5 in twelve months.
What Else Can Raise Your PSA
An elevated PSA result does not mean you have cancer. Inflammation in the prostate (prostatitis) is one of the most common non-cancerous causes. Research from Johns Hopkins found that men with more prostate inflammation had higher PSA levels, and the greater the inflammation, the higher the reading. The inflammation appears to disrupt the cells that produce PSA and makes blood vessels in the prostate more permeable, allowing PSA to leak into the bloodstream at higher rates.
Higher testosterone levels also correlate with higher PSA. Men with elevated testosterone had greater odds of a clinically abnormal PSA reading even without cancer. Benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate that’s extremely common in older men, pushes PSA levels up as well. All of this means that an abnormal PSA test is often the beginning of a diagnostic process, not a diagnosis in itself.
The Digital Rectal Exam
During a digital rectal exam (DRE), a doctor inserts a gloved, lubricated finger into the rectum to feel the back surface of the prostate gland, where most prostate cancers start. They’re checking for bumps (nodules), hard areas, or unusual texture that could indicate cancer. The exam takes about 10 to 15 seconds and can feel uncomfortable but shouldn’t be painful.
A DRE can detect some cancers that a PSA test misses, and vice versa, which is why the two are often used together. However, a DRE can only assess the rear portion of the gland, so cancers in other areas may not be felt.
Follow-Up Blood Tests After an Abnormal PSA
If your PSA comes back elevated, you don’t necessarily jump straight to a biopsy. Newer blood tests can help clarify whether the elevation is likely caused by aggressive cancer or something less concerning.
The 4Kscore test measures several prostate-related proteins and scores your risk of having aggressive prostate cancer. It’s specifically designed to help men avoid unnecessary biopsies. The Prostate Health Index (PHI) combines three different blood measurements into a single score that estimates the likelihood of finding cancer if a biopsy were performed. Both tests sit between a standard PSA result and a biopsy, giving you and your doctor better information before deciding on next steps.
MRI and Biopsy
When blood tests and physical exams point toward a possible cancer, the next step is usually an MRI of the prostate. The MRI identifies suspicious areas in the gland, which can then be targeted during a biopsy for more accurate sampling.
Two biopsy approaches are used today. A transrectal biopsy inserts a needle through the rectal wall, while a transperineal biopsy goes through the skin between the scrotum and rectum. Both detect clinically significant cancer at comparable rates when guided by MRI. The key difference is infection risk: transperineal biopsies carry significantly fewer infectious complications, with roughly one-third the rate of serious infections compared to the transrectal approach. Transperineal biopsies can even be performed safely without antibiotics. The tradeoff is that transperineal procedures tend to cause more discomfort during the process. Rates of bleeding and urinary retention are similar between the two.
During a biopsy, small tissue samples are taken from multiple areas of the prostate. You’ll typically receive local anesthesia, and the procedure takes about 15 to 30 minutes. Expect some blood in your urine, semen, or stool for a few days afterward.
How Biopsy Results Are Graded
If cancer is found, a pathologist examines the tissue under a microscope and assigns a Gleason score ranging from 6 to 10. The score is built by grading the two largest areas of cancer in the sample on a scale of 1 to 5 based on how abnormal the cells look, then adding those two grades together. A tissue sample where the largest cancerous area scores 3 and the next largest scores 5 would receive a Gleason score of 8.
- Gleason 6: Low-grade cancer. Cells still look a lot like healthy prostate tissue. These cancers grow slowly and are the least likely to spread.
- Gleason 7: Moderate-grade cancer. Cells look somewhat different from healthy tissue.
- Gleason 8, 9, or 10: High-grade cancer. Cells look very different from normal tissue, grow faster, and are more likely to spread beyond the prostate.
Your Gleason score plays a major role in determining whether treatment is recommended right away or whether active surveillance (regular monitoring without immediate treatment) is a safe option.
When To Start Screening
The U.S. Preventive Services Task Force recommends that men aged 55 to 69 make an individual decision about PSA screening after weighing the benefits and risks with their doctor. For men 70 and older, routine PSA screening is not recommended because the potential harms, including overdiagnosis and unnecessary treatment, tend to outweigh the benefits at that age.
If you’re at higher risk, the timeline shifts earlier. African American men develop prostate cancer at younger ages and die from it at higher rates than other groups. Men with a family history, particularly those with multiple first-degree relatives who had prostate cancer, also face elevated risk and earlier onset. Both groups may reasonably begin screening before age 55. Men who carry inherited changes in the BRCA1 or BRCA2 genes are also advised to discuss prostate screening with their doctors, with guidelines particularly emphasizing screening for those with BRCA2 changes.
Symptoms That Prompt Evaluation
Early prostate cancer usually causes no symptoms at all, which is precisely why screening matters. By the time symptoms appear, the disease may be more advanced. Locally advanced prostate cancer can cause blood in the urine or semen, along with persistent pain in the back, hips, or pelvis.
Many of the urinary symptoms people associate with prostate cancer, such as frequent urination at night, a weak stream, difficulty starting or stopping, or a feeling that the bladder hasn’t fully emptied, are far more commonly caused by BPH or prostatitis. These symptoms deserve evaluation regardless, because they affect your quality of life and occasionally signal something more serious. But experiencing them does not mean cancer is likely.