My PSA increased from 11 to 13. Should I be worried? | Dr Dilanka De Silva

Many of my patients have asked for simpler explanations of cancer tests and what the numbers in their reports actually mean. An elevated PSA can be worrying, but it does not automatically mean prostate cancer. I hope these articles help answer some of the common questions I hear in clinic.

Who is this article for?

This article is for men who:

• have been told their PSA is elevated or rising;
• have benign prostatic hyperplasia (BPH);
• are considering a prostate MRI or biopsy;
• have had previous prostate investigations but their PSA remains elevated; or
• want to better understand how doctors estimate the risk of clinically significant prostate cancer.

The question

A 64-year-old gentleman recently came to see me after noticing that his PSA had increased from 11 ng/mL to 13 ng/mL over two years.

Naturally, his question was:

“My PSA has increased from 11 to 13. Should I be worried that I have prostate cancer?”

The short answer

Not necessarily.

PSA is produced by prostate tissue, but an elevated PSA does not automatically mean prostate cancer.

A rise from 11 to 13 needs to be taken seriously and interpreted properly, but the PSA number by itself cannot tell us the diagnosis.

I would want to understand the prostate size, PSA density, MRI findings, family history, previous investigations and whether there are other factors that may have influenced the PSA.

The PSA tells us that we should assess the risk. It does not, by itself, tell us the diagnosis.

For men being assessed for an elevated PSA in Melbourne, modern prostate cancer investigation increasingly combines PSA, prostate volume, PSA density and MRI rather than relying on one number alone.

Clinical observation

The gentleman I reviewed had a long history of benign prostatic hyperplasia, or BPH.

He had previously been reassured that his enlarged prostate was likely contributing to his PSA.

What interested me was not simply the change in PSA, but how that PSA should be interpreted alongside his prostate size and previous investigations.

One of the realities of prostate cancer assessment is that surveillance does not look identical for every man.

Some men need repeat PSA testing.

Others may need a multiparametric MRI.

For some, biopsy eventually becomes appropriate.

For others, careful surveillance may remain reasonable.

None of these decisions should be made from one PSA result alone.

Age, family history, prostate volume, PSA density, MRI findings and previous biopsy results can all change the appropriate next step.

That naturally raises the question:

How should an elevated PSA be investigated today?

What surprised me

One of the most useful lessons in modern prostate cancer assessment is that a PSA number can look very different once you know how large the prostate actually is.

A PSA of 13 in a relatively small prostate does not necessarily carry the same level of concern as a PSA of 13 in a substantially enlarged prostate.

That does not mean a large prostate rules out cancer.

It means that we need context.

And one of the best ways of adding that context is a calculation many patients have never heard of:

PSA density.

Understanding the science

Why Can PSA Increase?

One of the biggest misconceptions is that an elevated PSA automatically means prostate cancer.

It does not.

PSA can increase for several reasons, including:

• benign prostatic hyperplasia (BPH);
• prostate cancer;
• inflammation or infection involving the prostate or urinary tract;
• urinary retention;
• recent prostate or urinary procedures; and
• other temporary factors that may influence the PSA result.

Some medicines used to treat an enlarged prostate can also lower PSA, which needs to be taken into account when interpreting the result.

This is why I rarely find a single PSA number useful in isolation.

The important question is not simply:

“Is the PSA high?”

It is:

“Why is it high, and how concerning is it in the context of this particular man?”

One number on the MRI that can completely change how we interpret PSA

Whenever I review a prostate MRI, one measurement that is particularly useful is:

Prostate volume.

A larger benign prostate can produce more PSA simply because there is more prostate tissue producing it.

This is why the same PSA result can have a different meaning in two men with very different prostate sizes.

That leads us to PSA density.

The important number many patients have never heard of: PSA density

PSA density compares the PSA level with the size of the prostate.

The calculation is simple:

PSA density = PSA ÷ prostate volume

In this gentleman:

PSA = 13 ng/mL

Prostate volume = 80 mL

Therefore:

13 ÷ 80 = approximately 0.16 ng/mL/cc

What does that number mean?

In general, as PSA density increases, the likelihood of clinically significant prostate cancer also increases.

However, I would not interpret 0.15 or 0.20 as a rigid pass-or-fail threshold.

Modern assessment combines PSA density with the MRI result.

Current European guidance shows that the risk associated with a PSA density of 0.16 can be very different depending on whether the MRI is reassuring or highly suspicious. PSA density and the PI-RADS MRI score provide much more useful information when considered together than either does in isolation.

For example, in pooled data reviewed by the European Association of Urology, a negative MRI had a negative predictive value of approximately 84% for clinically significant prostate cancer overall.

When the MRI was negative and PSA density was below 0.15, that increased to approximately 90%.

In patient language:

A reassuring MRI together with a lower PSA density can make clinically significant cancer less likely—but it does not reduce the risk to zero.

That is why the calculation is not simply:

PSA → biopsy

It is more like:

PSA + prostate size + PSA density + MRI + clinical risk → appropriate next step

Why MRI has changed prostate cancer diagnosis

Multiparametric MRI has transformed the way we investigate men with a persistently concerning PSA.

MRI can identify suspicious areas within the prostate and help guide biopsy towards those areas rather than relying only on systematic sampling.

It can also help some men avoid an immediate biopsy when the MRI is reassuring and the overall clinical risk is sufficiently low.

Current European guidance strongly supports using prostate MRI as part of the diagnostic pathway for men with suspected clinically significant prostate cancer.

But MRI is not perfect.

It should be interpreted together with:

• PSA and PSA trend;
• prostate volume;
• PSA density;
• PI-RADS score;
• family history;
• previous biopsy results; and
• the overall clinical picture.

What did the PROMIS trial show?

The PROMIS trial was one of the landmark studies that helped establish MRI as an important test before prostate biopsy.

In that study, multiparametric MRI had a sensitivity of approximately 93% for clinically significant prostate cancer, compared with approximately 48% for standard transrectal ultrasound-guided biopsy using the study definitions.

The investigators also estimated that using MRI as a triage test could allow approximately 1 in 4 men to avoid an immediate biopsy.

For patients, the message is not that MRI detects every cancer.

It does not.

The message is that MRI gives us much more information before deciding who actually needs a biopsy.

What did the PRECISION trial show?

The PRECISION trial took this concept a step further.

Men with a raised PSA who had not previously undergone prostate biopsy were assigned either to:

• an MRI-based diagnostic pathway, or
• standard systematic biopsy.

In the MRI group, men with a reassuring MRI could avoid immediate biopsy, while men with suspicious lesions underwent targeted biopsy.

The MRI-based strategy detected more clinically significant prostate cancers while detecting fewer lower-grade cancers that may never have caused harm.

This helped move prostate cancer diagnosis away from the old idea that every concerning PSA should automatically lead to the same biopsy strategy.

If an MRI shows a suspicious area, what happens next?

The next question is not simply whether a biopsy is performed.

The more useful question is:

“If a biopsy is needed, how should the suspicious area be sampled?”

Modern prostate biopsy is increasingly performed through the transperineal route, with MRI-targeted samples taken from suspicious areas.

Depending on the clinical situation, additional systematic or perilesional samples may also be taken.

The exact biopsy strategy depends on factors such as:

• the MRI findings;
• PI-RADS score;
• location of the suspicious lesion;
• prostate size;
• whether the patient has undergone a previous biopsy; and
• the biopsy technique being used.

Current EAU evidence supports MRI-targeted biopsy for suspicious lesions and shows that the optimal combination of targeted, systematic and perilesional sampling depends on the individual diagnostic setting.

The goal is not simply to take the largest number of biopsy samples.

The goal is to sample the prostate accurately enough to detect clinically significant cancer while avoiding unnecessary procedures where possible.

Is the digital rectal examination still useful?

Yes—but a normal examination does not rule out prostate cancer.

Many patients assume that if their doctor examines the prostate and it feels normal, cancer has been excluded.

Unfortunately, it is not that simple.

In a systematic review of digital rectal examination performed in primary care, the pooled sensitivity was approximately 51%.

In simple terms, DRE alone missed a substantial proportion of prostate cancers in the populations studied.

That does not mean that DRE has no value.

An abnormal examination can increase suspicion. Current European guidance notes that an abnormal DRE together with an elevated PSA substantially increases the likelihood of a positive biopsy.

But a reassuring examination should not be used by itself to exclude cancer.

Today, PSA, MRI and overall risk assessment provide information that examination alone cannot provide.

What happens if cancer is found?

If biopsy confirms prostate cancer, one of the most important results is the ISUP Grade Group.

Many patients are familiar with the Gleason score.

The modern Grade Group system makes those results easier to understand and helps describe how the cancer is likely to behave.

The grading system itself does not determine treatment in isolation.

PSA, stage, MRI findings, amount of cancer in the biopsy and other clinical factors also matter.

But one point is particularly important:

Gleason 3+4 and Gleason 4+3 are not the same disease, even though both add up to seven.

In 3+4, pattern 3 is the dominant pattern.

In 4+3, the higher-grade pattern 4 predominates.

That difference matters when estimating risk and considering treatment.

What does this mean for men in Australia?

In Australia, eligible men being investigated for suspected prostate cancer may have access to Medicare-subsidised multiparametric prostate MRI.

MBS item 63541 applies to prostate mpMRI for the detection of cancer when the relevant Medicare criteria are met and the examination is requested by a specialist in urology, radiation oncology or medical oncology. The item remains current in the July 2026 MBS schedule.

For eligible men who already have biopsy-confirmed prostate cancer and are undergoing active surveillance, MBS item 63543 provides a separate pathway for prostate MRI in defined circumstances.

Not every man with an elevated PSA will meet the Medicare criteria.

And Medicare eligibility should not determine whether a test is medically appropriate.

The clinical decision still depends on the individual’s PSA, examination, prostate size, family history, previous investigations and overall level of risk.

Complex cases may benefit from multidisciplinary input involving urology, radiology, pathology, medical oncology and radiation oncology where appropriate.

What would I usually consider when a PSA is elevated?

Every man is different, and a PSA result should be interpreted in context.

Factors that may influence the next step include:

• age and general health;
• the current PSA and previous PSA results;
• prostate volume;
• PSA density;
• family history of prostate cancer;
• inherited cancer risk, including BRCA2 where relevant;
• MRI findings and PI-RADS score;
• previous biopsy results;
• urinary symptoms, infection or inflammation; and
• medicines that can alter PSA.

Current European guidance also recognises BRCA2 carriers and men with significant family histories as groups in whom prostate cancer risk deserves particular consideration.

Depending on these findings, the appropriate next step may involve repeat assessment, prostate MRI, ongoing surveillance or biopsy.

The aim is not to biopsy every man with an elevated PSA.

The aim is to identify the men most likely to have clinically significant prostate cancer while safely avoiding unnecessary procedures where possible.

So, should an elevated PSA from 11 to 13 cause panic?

No.

But it should not simply be ignored either.

A change from 11 to 13 over two years provides one piece of information.

The next questions are more useful:

How large is the prostate?

What is the PSA density?

Does the MRI show anything suspicious?

Which PI-RADS score was reported?

Is there a significant family history?

Has the patient had a previous biopsy?

Are there other reasons the PSA may have changed?

Only when those pieces are put together can we make a sensible assessment of risk.

The one message I want patients to remember

An elevated PSA is the beginning of the investigation—not the diagnosis.

The best decisions are made by combining:

• PSA and its trend over time;
• prostate volume;
• PSA density;
• multiparametric MRI findings;
• PI-RADS score;
• family history and inherited risk;
• previous investigations;
• appropriate biopsy when required; and
• ISUP Grade Group if cancer is diagnosed.

There is no single surveillance pathway that is right for every man.

Good prostate cancer assessment still depends on combining modern technology with thoughtful, individualised clinical judgement.

Do not interpret the PSA alone.

Understand the whole risk picture.

Key takeaways

• An elevated PSA is a reason for further assessment—not a diagnosis of prostate cancer.
• Prostate size matters because a larger benign prostate can produce more PSA.
• PSA density is useful, but it should be interpreted together with MRI findings rather than using one rigid cut-off.
• Multiparametric MRI has become central to deciding who may need biopsy and where suspicious areas should be sampled.
• The aim of modern assessment is to detect clinically significant prostate cancer while safely avoiding unnecessary procedures where possible.

About Dr Dilanka De Silva

Dr Dilanka De Silva is a Medical Oncologist and Cancer Genetics Physician consulting in Melbourne, Australia, with a special interest in precision oncology, cancer genetics and complex cancer second opinions.

He provides prostate cancer assessment and second opinions in Melbourne and also reviews international patients from Sri Lanka, the Maldives, Indonesia and the Philippines.

Where clinically indicated, patients can be referred for contemporary prostate imaging and specialist urological assessment, including high-quality multiparametric prostate MRI.

References

1. European Association of Urology. EAU guidelines on prostate cancer. Uroweb. Accessed August 4, 2026. https://uroweb.org/guidelines/prostate-cancer
2. Kasivisvanathan V, Rannikko AS, Borghi M, et al. MRI-targeted or standard biopsy for prostate-cancer diagnosis. N Engl J Med. 2018;378(19):1767-1777. doi:10.1056/NEJMoa1801993
3. Ahmed HU, El-Shater Bosaily A, Brown LC, et al. Diagnostic accuracy of multi-parametric MRI and TRUS biopsy in prostate cancer (PROMIS): a paired validating confirmatory study. Lancet. 2017;389(10071):815-822. doi:10.1016/S0140-6736(16)32401-1
4. Naji L, Randhawa H, Sohani Z, et al. Digital rectal examination for prostate cancer screening in primary care: a systematic review and meta-analysis. Ann Fam Med. 2018;16(2):149-154. doi:10.1370/afm.2205
5. Epstein JI, Egevad L, Amin MB, et al. The 2014 International Society of Urological Pathology (ISUP) consensus conference on Gleason grading of prostatic carcinoma: definition of grading patterns and proposal for a new grading system. Am J Surg Pathol. 2016;40(2):244-252. doi:10.1097/PAS.0000000000000530
6. Australian Government Department of Health, Disability and Ageing. Item 63541. Medicare Benefits Schedule. Accessed August 14, 2026. https://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=63541
7. Australian Government Department of Health, Disability and Ageing. Item 63543. Medicare Benefits Schedule. Accessed August 14, 2026. https://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=63543&qt=item

Frequently asked questions (FAQs)

1. Does a PSA of 13 mean I have prostate cancer?

No.

A PSA of 13 is elevated and deserves appropriate assessment, but PSA alone cannot diagnose prostate cancer.

Benign prostate enlargement and other conditions can also increase PSA.

2. Can an enlarged prostate cause a high PSA?

Yes.

A larger benign prostate contains more PSA-producing tissue and can therefore produce a higher PSA.

That is one reason prostate volume and PSA density are useful.

3. What is PSA density?

PSA density divides the PSA level by the prostate volume.

For example:

PSA 13 ÷ prostate volume 80 mL = PSA density approximately 0.16 ng/mL/cc.

It helps us understand whether the PSA appears proportionate to the amount of prostate tissue present.

4. Is a PSA density above 0.15 dangerous?

Not by itself.

Risk generally increases as PSA density rises, but current assessment combines PSA density with MRI findings and other clinical factors rather than using one number as a universal yes-or-no threshold.

5. Can a normal prostate MRI rule out cancer?

No.

A reassuring MRI can significantly lower the probability of clinically significant prostate cancer, particularly when PSA density is also low, but the risk does not become zero.

In pooled data cited by the EAU, the negative predictive value of MRI for clinically significant disease was about 84% overall, increasing to approximately 90% when PSA density was below 0.15.

6. Do I always need a biopsy if my PSA is elevated?

No.

Whether biopsy is appropriate depends on the PSA, PSA density, MRI findings and overall risk.

Current diagnostic pathways allow some men with reassuring MRI findings and low clinical suspicion to undergo surveillance rather than immediate biopsy.

7. Does a normal rectal examination rule out prostate cancer?

No.

DRE can provide useful information, particularly when abnormal, but a normal examination cannot exclude prostate cancer.

It should be considered alongside PSA, MRI and the overall clinical picture.

8. What is the difference between Gleason 3+4 and 4+3?

Both add up to seven, but they do not represent exactly the same cancer biology.

In 3+4, the lower-grade pattern 3 predominates.

In 4+3, the higher-grade pattern 4 predominates.

Grade Group 3 disease therefore generally behaves more aggressively than Grade Group 2 disease.

Disclaimer: This article provides general educational information and does not replace individual medical advice. PSA results, MRI findings and decisions regarding prostate biopsy should be interpreted in the context of the individual patient and discussed with the treating medical team.

Dr Dilanka De Silva
MBBS, MRCP(UK), MRCP(UK SCE Oncology), FRACP, PhD
Medical Oncologist & Cancer Genetics Physician
Memorial Sloan Kettering Cancer Center Fellow (New York, USA)