The addition of systematic prostate biopsy enhances the detection of clinically significant prostate cancer compared to MRI-targeted biopsy alone. However, there is growing interest in using only MRI-targeted biopsy. We sought to evaluate PSA density as an adjunctive predictor of clinically significant prostate cancer detection in men undergoing combined biopsy and as a potential metric to stratify which patients may reasonably avoid systematic biopsies in favor of MRI-targeted biopsy only.
Men with elevated PSA and/or abnormal digital rectal exam found to have an MRI-visible prostate lesion underwent MRI-targeted and systematic prostate biopsy. Primary outcomes were clinically significant cancer detection rates by MRI-targeted, systematic biopsy, and combined biopsy across four discrete PSA density intervals (<0.1, >0.1 and <0.15, >0.15 and <0.2, and >0.2 ng/ml/cm3). Secondary outcomes were the added value of systematic biopsy relative to MRI-targeted biopsy alone.
Among men with PI-RADS >2 lesions, as PSA density surpassed each interval, the rate of grade group >3 cancer detection approximately doubled (<0.1:9.3%, >0.1 and <0.15:18.2%, >0.15 and <0.2:36%, and >0.2:61.2%). For PSA density >0.2, added detection of clinically significant cancer with systematic biopsy was low(2%, 95%CI:0.4%-5.9%).
Given an approximate doubling in grade group >3 cancer detection on combined biopsy with rising PSA density intervals, clinicians may consider PSA density in risk stratifying men at high risk of clinically significant prostate cancer. Clinicians may consider omitting systematic biopsy for targeted biopsy of MRI-visible lesions in patients with PSA density >0.2ng/ml/cm3, as systematic biopsy results in low rates of additional clinically significant cancer detection.
The Journal of urology. 2025 Feb 14 [Epub ahead of print]
Michael Ahdoot, Aurash Naser-Tavakolian, John R Heard, Cheyenne Williams, Michael Daneshvar, Patrick Gomella, Samhita Mallavarapu, Minhaj Siddiqui, Michael Nazmifar, Joanna Shih, Baris Turkbey, Bradford Wood, Peter Pinto
Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA., Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA., Division of Urology, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA., Department of Urology, University of California - Irvine, Irvine, CA, USA., Assistant Editor, The Journal of Urology., Biometric Research Program, Division of Cancer Treatment and Diagnosis, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA., Molecular Imaging Program, Center for Cancer Research, National Institutes of Health, Bethesda, MD, USA., Center for Interventional Oncology, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.