Biopsy to Detect Prostate Cancer – when is it needed?

Indications for Prostate Biopsy

Digital Rectal Exam (DRE)
suspicious for cancer at any PSA level
PSA above 3 ng/mL High Risk of prostate cancer based on multiple risk factors.
TRUS (transrectal ultrasound) Guided Biopsy. In some circumstances, Doppler ultrasound- guided or MRI-guided biopsy may be preferred or required. If TRUS-guided-biopsy not done, follow up in 6 to 12 months with PSA/DRE. Consider testing FPSA, PHI, and/or PCA3 if PSA is between 3 and 10 ng/mL. Measure free PSA (FPSA), PHI (Prostate Health Index), or PCA3 in patients with PSA 3 - 10 ng/mL

Basis for these recommendations:

1. PSA level correlates with risk of cancer.

  • The Prostate Cancer Prevention Trial found that 15% of men with PSA above 4.0 ng/mL and normal digital rectal exam had biopsy-proven prostate cancer.
  • Roughly 1 out of 3 men (30%- 35%) with PSA between 4 and 10 ng/mL will be found to have cancer.
  • Total PSA levels above 10 ng/mL put a man in the 67% risk of prostate cancer slot.
2. A combination of risk factors including family history, ethnicity, age, DRE and PSA may put a man at higher risk for prostate cancer.

  • Risk calculation tools, while not yet tested in clinical trials, can be useful and are available to doctors and patients.
3. PHI above 35, percent free PSA below 10%, and/or PCA3 score above 35 are "strongly suspicious for prostate cancer" (NCCN).

  • Especially for higher risk patients, these "Biomarker" tests are useful for indicating whether further biopsy is needed after a first biopsy proves negative for prostate cancer. They are not recommended as initial screening tests.
MRI (Magnetic Resonance Imaging) Guided Biopsy:

  • "MRI-guided prostate biopsy may be used in patients who have a rising PSA level yet a negative ultrasound-guided biopsy. It also may be used in situations where a diagnostic prostate MRI performed due to rising PSA demonstrates a very small abnormality that may not be easily targeted by ultrasound. MRI is also useful in patients who have previously undergone a biopsy and want to improve the sensitivity of the procedure and the precision of the biopsy."(

References & Links