PSA, % Free

Other names: PSA, % Free, PSA, FREE

check icon Optimal Result: 25 - 50 %.

Prostate-specific antigen (PSA) is a protein produced by the prostate. In the bloodstream, PSA exists in two forms:

  • Free PSA – not attached to other proteins

  • Bound PSA – attached to carrier proteins

Total PSA measures both forms combined.
PSA, % Free shows what percentage of the total PSA is unbound:
(free PSA ÷ total PSA) × 100.

This percentage helps determine whether an elevated PSA level is more likely due to prostate cancer or a benign condition such as benign prostatic hyperplasia (BPH) or prostatitis. Cancer tends to produce more bound PSA, lowering the % free PSA.


Why PSA, % Free Is Clinically Important

When the total PSA is between 4–10 ng/mL—often called the diagnostic gray zone—PSA alone cannot reliably distinguish cancer from benign causes.

The % free PSA significantly improves risk assessment and helps determine who may benefit from a prostate biopsy.

General interpretation:

  • Lower % free PSA = higher likelihood of prostate cancer

  • Higher % free PSA = more consistent with benign conditions


Prostate Cancer Risk by % Free PSA and Age

Men with total PSA between 4–10 ng/mL and a non-suspicious digital rectal exam (DRE)
Source: Catalona et al., JAMA 1998

% Free PSA Risk (Age 50–64) Risk (Age 65–75)
0.00–10.00% 56% 55%
10.01–15.00% 24% 35%
15.01–20.00% 17% 23%
20.01–25.00% 10% 20%
>25.00% 5% 9%

How to use this:

  • A % free PSA below 10% indicates the highest likelihood of prostate cancer in this PSA range.

  • A % free PSA above 25% suggests a low risk, and many men may be able to avoid biopsy.

  • The middle ranges (10–25%) represent intermediate risk, and further clinical evaluation is usually recommended.


How Total PSA, Free PSA, and % Free PSA Work Together

  • Total PSA gives the overall PSA level.

  • Free PSA measures the unbound portion.

  • % Free PSA helps refine cancer risk when total PSA is moderately elevated.

Using these together helps clinicians reduce unnecessary biopsies while still identifying men at meaningful risk for prostate cancer.

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What does it mean if your PSA, % Free result is too low?

Interpreting PSA Results: Key Factors

Total PSA

PSA levels naturally increase with age, and different age groups have different expected ranges (ng/mL):

  • Age ≤49: 0.0–2.5

  • Age 50–59: 0.0–3.5

  • Age 60–69: 0.0–4.5

  • Age ≥70: 0.0–6.5

A value above the age-adjusted range may suggest an increased risk of prostate cancer, but it is not diagnostic. Total PSA can also rise due to benign prostatic hyperplasia (BPH), prostatitis, recent ejaculation, or even catheterization. Because total PSA alone is nonspecific, clinicians use additional measures—especially free PSA and % free PSA—to refine interpretation.


Free PSA and the Free-to-Total PSA Ratio

PSA circulates in two forms:

  • Free PSA: unbound

  • Bound PSA: attached to proteins

The % free PSA is calculated as:
(free PSA ÷ total PSA) × 100

How to interpret it:

  • Higher % free PSA: More consistent with benign conditions

  • Lower % free PSA: Suggests a higher likelihood of prostate cancer

Typical interpretive thresholds:

  • 0–10%: Risk of cancer can be as high as ~50–60%

  • >25%: Risk drops to roughly 8–15% (depends on age)

These values help guide whether a biopsy is appropriate, especially when total PSA is in the gray zone of 4–10 ng/mL.


When Total PSA Is Normal but % Free PSA Is Low

This combination can be confusing, but it does occur.

What it means:

  • Normal total PSA: Typically suggests no significant prostate disease

  • Low % free PSA (especially <10–15%): Suggests increased production of bound PSA, which may occur in prostate cancer—even before total PSA rises

Possible explanations:

  • Very early-stage prostate cancer

  • Biological variation

  • Assay variability

  • Temporary effects (e.g., inflammation)

Recommended next steps:

  • Repeat PSA in several weeks or months to look for trends

  • Digital rectal exam (DRE)

  • MRI or targeted imaging

  • Biopsy, if clinical suspicion remains elevated

Context always matters. Family history, race, age, prior PSA history, and symptoms must be included in the assessment.


PSA Kinetics

How PSA changes over time can be as important as the absolute value:

  • PSA Velocity: Speed of change; a rapid rise raises concern

  • PSA Doubling Time: Faster doubling times suggest more aggressive disease

These metrics are especially useful after cancer treatment or in active surveillance programs.


Non-Cancer Causes of Elevated PSA

Several benign conditions can raise PSA:

  • BPH (benign prostate enlargement)

  • Prostatitis or infection

  • Recent ejaculation

  • Prostate manipulation (e.g., catheterization)

  • Long bike rides (less common but documented)

These must be considered before assuming cancer risk.


Age-Specific Cancer Risk Using % Free PSA

For men with non-suspicious DRE and total PSA between 4.0–10.0 ng/mL
(Roche E602 immunoassay system, 2015)

% Free PSA 50–59 yrs 60–69 yrs ≥70 yrs
≤10% 49.2% 57.5% 64.5%
11–18% 26.9% 33.9% 40.8%
19–25% 18.3% 23.9% 29.7%
>25% 9.1% 12.2% 15.8%

Interpretation:

  • ≤10% free PSA: Highest cancer probability

  • >25% free PSA: Lowest probability

  • Risk increases with age in every category

Note: In very low total PSA ranges (<1–2 ng/mL), calculation of % free PSA may not be technically possible or clinically meaningful.

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