Background: The controversy surrounding prostate cancer (PCa) screening resulted in the United States Preventative Services Task Force (USPSTF) and several primary care societies to recommend against this practice. We examined the characteristics of men evaluated in a large urology practice for an elevated prostate specific antigen (PSA) and the subsequent PCa diagnoses since the USPTF recommendation. Methods: Characteristics of all men presenting for an elevated PSA from August 2011 to August 2014 were prospectively collected in a database. Age at the time of biopsy, self-declared race, insurance status, family history, digital rectal examination findings, PSA within 6 months of biopsy, biopsy history, prostate volume, number of cores sampled, pathologic read (number and percent cores positive, Gleason grading) were all recorded. Kruskall-Wallis rank sum tests were used to compare across all years with post-hoc Dunn’s tests for pairwise multiple comparisons using Bonferroni adjustment. Results: The number of men referred for elevated PSA dropped from 933 in year 1 to 754 by year 3 (19%) with a concomitant drop in the number of biopsies performed in newly referred men from 461 to 370 (20%). The group’s prostate biopsy volume decreased by 15% (1,133 biopsies in year 1 compared to 958 in year 3). Median pre-biopsy PSA increased across all years from 7.0 ng/ml to 8.1 ng/ml (p = 0.0006) with a rise in the proportion of men having PSAs > 10 from 28% to 38%. In the post-hoc analysis, median pre-biopsy PSA was significantly different between years 1 and 3 (p = 0.0002) and years 2 and 3 (p = 0.017) but not years 1 and 2 (p = 0.33). The biopsy positivity rate increased slightly from 46% to 50% across all years with a rise in the proportion of men having Gleason scores (GS) ≥ 8 from 21% to 30% (p = 0.0001). In the post-hoc analysis, median GS was significantly different between year 1 and year 3 (p < 0.0001) and year 2 to year 3 (p = 0.0004) but not year 1 to year 2 (p = 0.12). Conclusions: Our findings suggest a significant grade migration coincident with recommendations against PSA screening. While possibly desirable in the short term, should this trend continue we may miss the window of curability for many men.