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."(RadiologyInfo.org)
References & Links
- NCCN Guidelines for Patients, Prostate Cancer, 2015
- NCCN Guidelines for Prostate Cancer Early Detection. 2014 .pdf Requires log-in
- Prostate Cancer Diagnosis MSK
- Transrectal Ultrasound and Transrectal Biopsy in NCI Dictionary of Cancer Terms RadiologyInfo.org
- Ultrasound- and MRI-Guided Prostate Biopsy.
- Can Power Doppler enhanced transrectal ultrasound guided biopsy improve prostate cancer detection on first and repeat prostate biopsy? Eur Urol. 2004 Oct;46(4):451-6. Remzi M
- Doppler ultrasound measurement of resistance index in the diagnosis of prostate cancer. Huang W & team Tumori. 2015 May 18; Department of Urology, Hainan Provincial People`s Hospital, Hainan - PR China.
- Advances in ultrasound techniques for the diagnosis and staging of prostate cancer. . . . . Westendarp M & team. Archivos Españoles de UrologíaArch Esp Urol. 2015 Apr.[Article in Spanish]
- The impact of repeated prostate biopsies on sexual function and urinary symptoms . . . : can ecoDoppler reduce side effects? Arch Ital Urol Androl. 2014 Dec 30;86(4)/2014.4.356. (full text .pdf download) Quaresima L & team, Institute of Urology, AOU United Hospitals, Polytecnic University of Marche Region, Ancona, Italy.