Deciding whom to biopsy.

Area of Science:

• Urology
• Oncology
• Biostatistics

Background:

• Prostate-specific antigen (PSA) levels vary widely in men, and elevated PSA does not always indicate cancer.
• Biopsy results from the Prostate Cancer Prevention Trial (PCPT) reveal prostate cancer presence across all PSA levels, including "normal" ranges.
• The low specificity of total PSA for cancer detection complicates decisions regarding prostate biopsy.

Purpose of the Study:

• To explore differing viewpoints on selecting men for prostate biopsy.
• To evaluate the utility of PSA levels, PSA velocity, and risk prediction models in guiding biopsy decisions.
• To present arguments for PSA cut-off/velocity measures versus established risk nomograms.

Main Methods:

• Analysis of Prostate Cancer Prevention Trial (PCPT) biopsy data.
• Review of literature and clinical viewpoints on PSA testing and prostate biopsy selection.
• Comparison of PSA cut-off strategies, PSA velocity, and predictive risk models.

Main Results:

• Prostate cancer is detected at all PSA levels, with high-grade cancers found in men with "normal" PSA.
• PSA velocity may aid in identifying men likely to have cancer, with lower thresholds potentially suitable for younger men.
• A predictive model using PCPT data can incorporate multiple risk variables but currently excludes PSA velocity.

Conclusions:

• There is ongoing debate regarding the optimal use of PSA in selecting men for prostate biopsy.
• Differing approaches exist, including using PSA cut-offs or PSA velocity versus established risk nomograms.
• An individualized approach incorporating various risk factors is being developed, though PSA velocity's independent predictive value is debated.