An overview of serum prostatic surface antigen cut points for recommendation of prostatic biopsy

Patients in India frequently present with prostatic surface antigen (PSA) report and request for prostatic biopsy to rule out malignancy. With fear of harboring malignancy set in patient's mind, it becomes difficult to counsel them about absolute indications and need of biopsy. Whether serum PSA has same predictability in symptomatic patients in the Indian context for advising prostatic biopsy at same reference ranges as in western countries, remains to be answered.

Symptomatic patients between 45 and 70 years of age presenting with either raised serum PSA (>4 ng/ml) reports or abnormal digital rectal examination (DRE) were considered as cases. Standard 12 core transrectal ultrasound-guided prostatic biopsy was done. Statistical analysis using optimal cut points, an R package was done to overview different PSA cut points for the recommendation of prostatic biopsy.

A total of 534 patients were included. Mean age was 64 years. Malignancy was detected in total 77 patients (14.42%). Malignancy was identified in 3.59% (10/279) and 30% (63/210) patients at serum PSA ranges 4-10 ng/ml and serum PSA >10 ng/ml, respectively. Both, maximum sensitivity and specificity were found at PSA cut point 9.7 ng/ml. We evaluated these patients to identify the PSA cut point above which unnecessary biopsies will be avoided. We kept power of study maximum, i.e., 1 with confidence interval of 0.95.

PSA value 9.7 ng/ml should be considered as the cut point above which prostatic biopsy should be done to avoid unnecessary biopsies. Unless accompanied by abnormal DRE finding at PSA range 4-10 ng/ml, morbidity of prostatic biopsy procedure can be avoided using this cut-point.