Editing AUA: Early Detection of Prostate Cancer (2023) (section)

== Initial biopsy ==

=== Prostate MRI before biopsy ===
*'''<span style="color:#ff0000">MRI may be used prior to initial biopsy to increase the detection of GG2+ prostate cancer</span>'''
** Studies have demonstrated the clinical value of mpMRI and using this to guide biopsy decision-making can increase the likelihood of detecting clinically significant prostate cancer while lowering detection of insignificant disease. This is particularly true in patients with a prior negative prostate biopsy; data from patients who are biopsy naïve are less definitive.
** While some data suggest the benefit of a prebiopsy MRI in biopsy-naïve patients, conflicting reports moderate the enthusiasm for a strong recommendation.
** It is reasonable to obtain an mpMRI in biopsy-naïve patients prior to their first biopsy, but such a practice cannot be regarded as the standard approach based on the currently available evidence.
* '''Radiologists should utilize PI-RADS in the reporting of mpMRI imaging.'''
** '''<span style="color:#ff0000">Detection rates by PI-RADS score for</span>''' 
***'''Any prostate cancer'''
****'''PR 1-2: 15%'''
**** '''PR 3: 25%'''
**** '''PR 4: 58%'''
**** '''PR 5: 85%'''
***'''<span style="color:#ff0000">GG2+ prostate cancer</span>'''
****'''<span style="color:#ff0000">PR 1-2: 7%</span>'''
**** '''<span style="color:#ff0000">PR 3: 11%</span>'''
**** '''<span style="color:#ff0000">PR 4: 37%</span>'''
**** '''<span style="color:#ff0000">PR 5: 70%</span>'''
***Of the 23 studies that were pooled for these results, 10 reported on a per lesion analysis and 13 reported on a per patient analysis using an index lesion.
** '''Reader variability remains a challenge'''

=== Biopsy threshold ===
*'''<span style="color:#ff0000">May be tailored for select patients, similar to risk-stratified re-screening intervals</span>'''
**'''For patients with BRCA mutations, biopsy referral threshold should be 3 ng/mL'''
*'''<span style="color:#ff0000">Clinicians and patients may use validated risk calculators to inform the SDM process regarding prostate biopsy</span>'''
**'''<span style="color:#ff0000">Pre-biopsy risk calculators</span>'''
*** [https://www.prostatecancer-riskcalculator.com/seven-prostate-cancer-risk-calculators ERSPC]
***[https://riskcalc.org/PCPTRC/ PCPT V2]
*** [https://riskcalc.org/PBCG/ PBCG]
**** In one study, investigators compared PBCG with PCPT and concluded that PCPT performed better in minority groups.
*PSA velocity should not be used as sole indication for secondary biomarker, imaging, or a biopsy.
*'''Adjunctive urine or serum markers may be used when further risk stratification would influence the decision regarding whether to proceed with biopsy.'''
** Several blood and urine markers are available, alone or in combination, to further risk stratify patients with a mildly elevated PSA, typically between 2.5 and 10 ng/mL.
*** '''Serum based'''
****'''Percent free PSA'''
*****Most widely available adjunctive test
*****Lower percent free PSA is associated with greater likelihood of identifying prostate cancer on biopsy.
**** '''PSA density'''
*****Higher PSA density (serum PSA [ng/mL] divided by imaging measures of prostate volume [cc]) is associated with the risk of identifying clinically significant prostate cancer on biopsy
***** The Panel recognizes the continuous nature of risk associated with the spectrum of PSA density values and cautions against use of threshold values in isolation
****4Kscore
****IsoPSA
****Proclarix
****PHI
****STHLM-3
***'''Urine based'''
****Post-DRE Urine
*****PCA3
*****MPS
*****SelectMDx
*****TMPRSS:ERG
****Urine
*****ExoDx Prostate Intelliscore
*****MiR Sentinel
****Tissue
*****Confirm MDx
*** Such tests may be of value among patients with modestly elevated PSA tests, especially in patients with a prior negative biopsy in whom PSA alone is not recommended as the sole trigger for rebiopsy.
*'''When the risk of clinically significant prostate cancer is sufficiently low based on available clinical, laboratory, and imaging data, clinicians and patients may forgo near-term prostate biopsy.'''

=== Pre-biopsy counselling ===
*'''<span style="color:#ff0000">Patients undergoing a prostate biopsy should be informed that there is a risk of identifying a cancer, with a sufficiently low risk of mortality, that could safely be monitored with active surveillance rather than treated'''
** A brief pre-biopsy discussion about pathologic findings warranting active surveillance is expected to increase subsequent acceptance of active surveillance by patients and lower rates of treatment

=== Role of prostate biopsy in very elevated PSA ===
*'''<span style="color:#ff0000">If PSA > 50 ng/mL </span>'''(and no clinical concerns for infection or other cause for increased PSA (e.g., recent prostate instrumentation)), '''<span style="color:#ff0000">may omit a prostate biopsy in cases if (2):</span>'''
*#'''<span style="color:#ff0000">Biopsy poses significant risk (e.g., anticoagulation, significant comorbidity, frailty)</span>'''
*#'''<span style="color:#ff0000">Need for prostate cancer treatment is urgent (e.g., impending spinal cord compression from metastases)</span>''' 
** Imaging to establish extent of disease or confirm metastasis may be helpful if an immediate biopsy is not performed.