Algorithms,nomograms and the detection of indolent prostate cancer

Purpose  Prostate cancer is the most commonly diagnosed cancer in men. However, only about 12% of the men diagnosed with prostate cancer will die of their disease. Result  The serum PSA test can detect prostate cancers early, but using a PSA based cut-off indication for prostate biopsy results in unnecessary testing in app. 75–80% of the men and perhaps even more important the serum PSA test cannot tell how aggressive the cancer is. To decrease unnecessary testing different test results are often combined, converted into a probability and displayed graphically. There are more than 40 of these so called nomograms in the case of prostate cancer. These nomograms can be divided into two categories, namely those that predict biopsy outcome using results from serum determination(s) or non-invasive tests such as the DRE and TRUS. The second category represents those nomograms that predict tumor characteristics and prognosis using information coming from pathology review. Conclusion  The ultimate nomogram able to predict tumor characteristics and progression purely based on non-invasive testing will for a large part put an end to the negative side effects and uncertainties that coincide with the early detection of prostate cancer, if it will ever be made.     

Potential predictive factors of positive prostate biopsy in the Japanese population

Introduction There are numerous arguments for the predictive factors of positive prostate biopsies, differing according to race and region. This study aimed to determine predictive factors for a positive prostate biopsy in East Asian, especially Japanese men, using clinical, laboratory, and transrectal ultrasound (TRUS) findings. Methods Data were collected from 466 men who underwent a prostate biopsy for suspected prostate cancer. Variables analyzed including age, digital rectal examination (DRE) findings, prostate-specific antigen (PSA) level, PSA density, prostate volume, and TRUS findings. Logistic regression analysis and the Mann–Whitney U test were used for this study. Results Logistic regression analysis showed that significant predictors for a positive prostate biopsy for all patients were positive DRE results, prostate volume, and hypoechoic lesions on TRUS. Especially in the patients with PSA levels <10 ng/ml, the significant predictor for positive biopsy was prostate volume. The Mann–Whitney U test showed that significant predictors for a positive prostate biopsy in all patients were PSA density >0.15, positive DRE results, and prostate volume <25 cm³. Especially in patients with PSA levels <10 ng/ml, significant predictors for a positive prostate biopsy were prostate volume <25 cm³ and PSA density >0.15. Additionally, even if the data were confined to those patients with seven or more core biopsies, all the predictive factors shown in all patients were significant predictors in this category. Conclusion This study investigated potential predictors for positive prostate biopsy and demonstrated that prostate volume was an independent predictive factor for positive prostate biopsy in patients with PSA levels <10 ng/ml. In the future, we may be able to use our findings to create a nomogram for predicting positive prostate biopsy in Japanese men.     

Nomogram for predicting the probability of the positive outcome of prostate biopsies among Ghanaian men

Introduction and objectives

Several existing models have been developed to predict positive prostate biopsy among men undergoing evaluation for prostate cancer (PCa). However, most of these models have come from industrialized countries. We therefore, developed a prostate disease nomogram model to provide a basis for predicting a prostate biopsy outcome by correlating clinical indicators and diagnostic parameters among Ghanaian men.

Development and validation of a nomogram predicting the outcome of prostate biopsy based on patient age, digital rectal examination and serum prostate specific antigen

PURPOSE: We developed and validated a nomogram which predicts presence of prostate cancer (PCa) on needle biopsy. MATERIALS AND METHODS: We used 3 cohorts of men who were evaluated with sextant biopsy of the prostate and whose presenting prostate specific antigen (PSA) was not greater than 50 ng/ml. Data from 4,193 men from Montreal, Canada were used to develop a nomogram based on age, digital rectal examination (DRE) and serum PSA. External validation was performed on 1,762 men from Hamburg, Germany. Data from these men were subsequently used to develop a second nomogram in which percent free PSA (%fPSA) was added as a predictor. External validation was performed using 514 men from Montreal. Both nomograms were based on multivariate logistic regression models. Predictive accuracy was evaluated with areas under the receiver operating characteristic curve and graphically with loess smoothing plots. RESULTS: PCa was detected in 1,477 (35.2%) men from Montreal, 739 (41.9%) men from Hamburg and 189 (36.8%) men from Montreal. In all models all predictors were significant at 0.05. Using age, DRE and PSA external validation AUC was 0.69. Using age, DRE, PSA and %fPSA external validation AUC was 0.77. CONCLUSIONS: A nomogram based on age, DRE, PSA and %fPSA can highly accurately predict the outcome of prostate biopsy in men at risk for PCa.     

A nomogram based on age,prostate-specific antigen level,prostate volume and digital rectal examination for predicting risk of prostate cancer

Nomograms for predicting the risk of prostate cancer developed using other populations may introduce sizable bias when applied to a Chinese cohort. In the present study, we sought to develop a nomogram for predicting the probability of a positive initial prostate biopsy in a Chinese population. A total of 535 Chinese men who underwent a prostatic biopsy for the detection of prostate cancer in the past decade with complete biopsy data were included. Stepwise logistic regression was used to determine the independent predictors of a positive initial biopsy. Age, prostate-specific antigen (PSA), prostate volume (PV), digital rectal examination (DRE) status, % free PSA and transrectal ultrasound (TRUS) findings were included in the analysis. A nomogram model was developed that was based on these independent predictors to calculate the probability of a positive initial prostate biopsy. A receiver-operating characteristic curve was used to assess the accuracy of using the nomogram and PSA levels alone for predicting positive prostate biopsy. The rate for positive initial prostate biopsy was 41.7% (223/535). The independent variables used to predict a positive initial prostate biopsy were age, PSA, PV and DRE status. The areas under the receiver-operating characteristic curve for a positive initial prostate biopsy for PSA alone and the nomogram were 79.7% and 84.8%, respectively. Our results indicate that the risk of a positive initial prostate biopsy can be predicted to a satisfactory level in a Chinese population using our nomogram. The nomogram can be used to identify and counsel patients who should consider a prostate biopsy, ultimately enhancing accuracy in diagnosing prostate cancer.     

Toward an MRI-based nomogram for the prediction of transperineal prostate biopsy outcome: A physician and patient decision tool

Purpose

To develop and internally validate a nomogram using biparametric magnetic resonance imaging (B-MRI)–derived variables for the prediction of prostate cancer at transperineal sector-guided prostate biopsy (TPSB).

Race is not independently associated with a positive prostate biopsy in men suspected of having prostate cancer

OBJECTIVES: To examine whether race is associated with the prostate biopsy result after controlling for other clinical factors in men undergoing ultrasound-guided prostate biopsy to evaluate an elevated serum prostate-specific antigen (PSA) or an abnormal digital rectal examination (DRE), or both. METHODS: We reviewed the records of all men undergoing transrectal ultrasound-guided prostate biopsy at our facilities from January 1990 through March 1998. This included 1056 white men and 874 black men. Patient age, serum PSA, indication for prostate biopsy, and race were examined for association with the biopsy result. RESULTS: Of the 1 930 black and white men who underwent prostate biopsy, 639 (33%) had cancer, including 355 (41%) of 874 black men and 284 (27%) of 1056 white men. Serum PSA, abnormal DRE, and age were independent predictors of a prostate biopsy being positive for cancer. Race was not an independent predictor of cancer being identified in the prostate biopsy. CONCLUSIONS: After controlling for PSA, DRE, and age, black men were not at an increased risk of a positive prostate biopsy relative to white men. Our data do not support the need to consider race when estimating the probability that a man has prostate cancer.     

Follow-up of men obtaining a six-core versus a ten-core benign prostate biopsy 7 years previously

The aim of this study is to evaluate the proportion of repeat biopsies after 7 years in men with an initial benign six- or ten-core biopsy as well as the incidence of prostate cancer (PC) in the repeat biopsies. In this retrospective longitudinal study, 116 men with an elevated prostate-specific antigen (PSA) and/or a suspicious digital rectal examination (DRE) who have had a benign prostate biopsy between January 1997 and September 1997 were included. Fifty-eight men had an initial benign six-core biopsy (median PSA 7.5 ng/ml, range 0.3–67) (group A), and 58 men had an initial benign ten-core biopsy (median PSA 7.5 ng/ml, range 0.8–91.4) (group B). We analysed men with a pathological PSA velocity, a persistently elevated PSA, an abnormal DRE, a high-grade prostatic intraepithelial neoplasia or atypical adenomatous hyperplasia, or atypical small acinar proliferation as indication for rebiopsy. Furthermore, we analysed a subgroup with exclusively an increased PSA velocity (>0.75 ng/ml per year) as indication for rebiopsy. In group A, 14 men had a follow-up biopsy. In this group, follow-up biopsies yielded PC in eight men (13.8%), six (10.3%) had a negative follow-up biopsy. In contrast, in group B only four men (3.4%) had a follow-up biopsy (P=0.005). Two of them (3.4%) had PC (P=0.02), two cases (3.4%) showed a benign histology (P=0.06). The use of an extended biopsy protocol at the initial evaluation reduces the number of repeat biopsies required and decreases the number of PC detection in the follow-up biopsy cohort.     

Prostate cancer gene 3 urine assay for prostate cancer in Japanese men undergoing prostate biopsy

Objectives: To examine the clinical utility of the prostate cancer gene 3 (PCA3) urine test in predicting prostate cancer in Japanese men undergoing prostate biopsy. Method: The study group included 105 men who underwent extended prostate biopsy based on an elevated serum prostate‐specific antigen (PSA). In all cases, the patients' race was Asian. Urine specimens were collected after digital rectal examination, and PCA3 score (PCA3/PSA mRNA) was determined in the urine using the APTIMA PCA3 assay. PCA3 score was investigated for a correlation with serum PSA, prostate volume (PV), PSA density and biopsy outcome. Results: All urine samples collected were successfully analyzed (i.e. the informative specimen rate was 100%). Biopsy showed prostate cancer in 38 men (36%). The PCA3 score was not associated with serum PSA nor PV. The median PCA3 score in prostate cancer was significantly higher than that in negative biopsy (59.5 vs 14.2 P < 0.0001). The probability of prostate cancer was 69% at a PCA3 score of more than 50 and 5% at a PCA3 score of less than 20. On multivariable logistic regression, PSA density (P < 0.05) and PCA3 score (P < 0.0001) were the independent predictors for prostate cancer. There was no significant difference in AUC between PCA3 score and PSA density. The combination of PCA3 score and PSA density increased the AUC from 0.72 for PSA alone to 0.88. Conclusion: The specificity of the PCA3 urine assay for prostate cancer was excellent in Japanese men undergoing biopsy. PCA3 score could improve the prediction for prostate cancer and help to better select men who might benefit from prostate biopsy.     

Screening for early prostate cancer in Germany. Preliminary results of a prospective multicenter trial

Summary To compare the efficacy of digital rectal examination (DRE) and serum prostate specific antigen (PSA) in early detection of prostate cancer, we initiated a prospective multicenter screening trial. In 12 542 men choosen at random with a mean age of 62 ( ± 7.5) a suspect DRE or a PSA level > 4.0 ng/ml was found in 2343 (20 %). Of the presently performed 744 biopsies, 157 revealed diagnosis of prostate cancer. Although further biopsies as well as the follow up of the 12 542 men are still missing, combination of DRE and PSA value > 4.0 ng/ml appears to be superior to DRE alone with a positive predictive value of 50 % versus 19 % in early detection of prostate cancer.      

Age, prostate-specific antigen, and digital rectal examination as determinants of the probability of having prostate cancer

Objectives. The decision to perform prostate biopsy has traditionally been based on an abnormal prostate-specific antigen (PSA) level or abnormal digital rectal examination (DRE) findings. For example, a 60-year-old man with a benign DRE and PSA level of 4.1 ng/mL would be counseled for biopsy, and the same man with a PSA level of 3.9 ng/mL might be counseled against biopsy. However, the difference in these PSA levels and in the likelihood of these two men having prostate cancer is not significant. We constructed a probability nomogram for the likelihood of detecting prostate cancer, thus aiding in the decision of whether to perform a prostate biopsy.Methods. Using multivariate logistic regression analysis and data from 2054 men (mean age 64 years) participating in the Tyrol Screening Project between January 9, 1993 and January 9, 1997, patient age, PSA level, and DRE findings were analyzed for their ability to determine the likelihood of finding prostate cancer on transrectal ultrasound-guided biopsy.Results. DRE was suspicious in 278 men (13.5%). Overall, 498 (24.5%) of 2054 men biopsied had prostate cancer. The probability of discovering cancer on biopsy was calculated using patient age, DRE findings, and PSA level.Conclusions. DRE status had a large influence on the likelihood of positive biopsy across all PSA and age ranges. A combination of PSA, DRE result, and age better defined the probability of a positive biopsy than any factor alone. Using this nomogram, the decision to proceed with or defer prostate biopsy can be based on an actual probability of discovering prostate cancer rather than a single PSA-based cutpoint. These data may aid physicians and patients in decision-making.     

Relationships between prostate-specific antigen and prostate volume in black and white men with benign prostate biopsies

Objectives. To determine whether the higher age-adjusted serum prostate-specific antigen (PSA) levels in black compared with white men with no clinical evidence of prostate cancer reflect racial differences in relationships between PSA and prostate volume.Methods. The age, PSA, findings on digital rectal examination (DRE), prostate volume, and PSA density were assessed prospectively in 810 consecutive, evaluable men who underwent prostate biopsy for suspected cancer but who had benign histologic findings.Results. Among the black and white patients, there were significant differences in age (mean 67.2 ± 8.1 and 65.9 ± 7.7 years, respectively, P = 0.02), PSA (median 4.7 and 3.9 ng/mL, respectively, P <0.0001), prostate volume (median 41 and 36 mL, respectively, P = 0.004), and PSA density (median 0.11 and 0.08 ng/mL/mL, respectively, P = 0.005). Multiple linear regression analyses showed that black race was significantly associated with increased prostate volume when controlled for age (P = 0.02), with increased PSA when controlled for prostate volume and age (P = 0.002), and with increased PSA density when controlled for age (P = 0.007). When controlled for prostate volume, PSA was not significantly different in black and white men 50 to 59 years old but was significantly greater in black men 60 to 69 and 70 to 79 years old (P = 0.02 and 0.002, respectively).Conclusions. On a volume/volume basis, the benign prostatic tissue of black men appears to contribute more PSA to the circulating blood than does the benign prostatic tissue of white men, and the difference increases with advancing age. These phenomena provide a reasonable explanation for the age-adjusted racial differences in the PSA of men with no clinical evidence of cancer.     

The relation of prostate biopsy results and ratio of free to total PSA in patients with a total PSA between 4–20 ng/mL

Objective: In this study our aim was to investigate the efficacy of free tototal PSA ratio in discrimination of benign prostate hyperplasia andprostate cancer.Materials and methods: A total of 194 patients, 52 to 82 years old (mean66.06 ± 0.47 years) with PSA levels between 4 to 20 ng/mL wereincluded into this study. Each patient underwent sextant prostate biopsyunder transrectal ultrasound guidance. The patients were divided into twogroups as PSA 4–10 and 10–20 ng/mL. Patients with benign and malignresults were compared with respect to age, total PSA level, free PSA leveland free/total (f/t) PSA ratio.Results: Biopsies revealed prostate cancer in 16 of 130 patients (12.3%)with serum PSA 4–10 ng/mL and in 10 of 64 patients (15.6%) with serumPSA 10–20 ng/ml. In both PSA groups free PSA and f/t PSA levels werestatistically significant, where total PSA levels were not. In patients with4–20 ng/mL total PSA levels and a cut off level of < 0.18 for f/t PSA, thesensitivity, specificity and positive predictive value for prostate cancerwere 88.5%, 53.6% and 20.4% respectively.Conclusion: Higher levels of PSA suggest prostate cancer, but stilladditional parameters are needed for patients with PSA 4–20 ng/mL, suchas free PSA and f/t PSA. Although a cut off level of < 0.18 for f/t PSA seemsto be the most accurate one to discriminate benign and malign diseasesfurther studies on larger groups of patients are needed.     

Prostate cancer screening: Role of digital rectal examination and prostate-specific antigen

Background: This study was designed to determine the efficacy of digital rectal examination (DRE) and serum prostate-specific antigen (PSA) for early detection of prostate cancer in men ≥50 years of age. Methods: A prospective single-center clinical trial was conducted to screen 644 asymptomatic men, who were elicited by newspaper and radio advertisements, with DRE and PSA. Quadrant biopsy examinations of the prostate were performed if PSA >4 ng/ml or if DRE was suspicious. Results: Thirty-seven percent of the men (n=241) had an abnormality of DRE or elevated PSA. Of the 163 patients who underwent transrectal ultrasound and quadrant biopsies of the prostate, 77% had normal biopsies, 14 (8%) had prostatic intraepithelial neoplasia, and 24 (15%) had carcinoma of the prostate. PSAs ranged from 0.3 to 65.5 ng/ml, with a mean of 2.35 and a median of 1.6. Ninety-five patients had a PSA >4 ng/ml, of whom 17 had a PSA >10 ng/ml. Sensitivity of PSA was 75% and specificity 87%; for DRE the sensitivity was 75% and the specificity 69%. Clinical stage of patients who underwent radical prostatectomy was B1 in 15 and B2 in five. Fifteen of 20 patients (75%) had organ-confined disease; the other five had specimen-confined disease. No patient was found to have nodal involvement. Conclusion: The combination of PSA and DRE seems to improve the stage of diagnosis of patients with prostate cancer. Larger, randomized studies will be necessary to evaluate the effect of screening on overall survival. The results of this study were presented at the 46th annual cancer symposium of the Society of Surgical Oncology, Los Angeles, California, March 18–20, 1993.     

Population Standards of Prostate Specific Antigen Values in Men over 40: Community Based Study in Turkey

Objective: To determine the prostate specific antigen (PSA) population standards of a cluster of Turkish men with no clinical evidence of prostate cancer. Patients and methods: We evaluated PSA values of the men who were living in a well-defined, rural district of Western Anatolia. Two hundred fifty-seven men agreed to participate in this population-based study. They underwent clinical examination, transrectal ultrasonography and serum PSA measurement. The association between serum PSA and age, prostate volume and age, PSA and prostate volume, and PSA density (PSAD) and age were assessed. Distributions of serum PSA levels, prostate volumes (PV), and PSAD values as a function of age were generated. Results: The upper limit of normal PSA concentration were 4.51 ng/ml for men aged 40–49 years, 4.36 ng/ml for 50–59 years, 6.17 ng/ml for 60–69 years, and 10.18 ng/ml for over 70 years. The upper limit of normal (95th percentile) for the serum PSA concentration increased with age. Across the entire age range, no correlation was found between the serum PSA concentrations and age while significant correlation was found between serum PSA concentration and prostate volume. Conclusion: In this present study, the PSA values in different age intervals showed higher than those observed in previous studies. The PSA values are mainly affected by prostate volume rather than age.     

Prostate cancer detection upon transrectal ultrasound-guided biopsy in relation to digital rectal examination and prostate-specific antigen level: what to expect in the Chinese population?

We investigated the prostate cancer detection rates upon transrectal ultrasound (TRUS)-guided biopsy in relation to digital rectal examination (DRE) and prostate-specific antigen (PSA), and risk factors of prostate cancer detection in the Chinese population. Data from all consecutive Chinese men who underwent first TRUS-guided prostate biopsy from year 2000 to 2013 was retrieved from our database. The prostate cancer detection rates with reference to DRE finding and PSA level of < 4, 4–10, 10.1–20, 20.1–50 and > 50 ng ml⁻¹ were investigated. Multivariate logistic regression analyses were performed to investigate for potential risk factors of prostate cancer detection. A total of 2606 Chinese men were included. In patients with normal DRE, the cancer detection rates were 8.6%, 13.4%, 21.8%, 41.7% and 85.2% in patients with PSA < 4, 4–10, 10.1–20, 20.1–50 and > 50 ng ml⁻¹ respectively. In patients with abnormal DRE, the cancer detection rates were 12.4%, 30.2%, 52.7%, 80.6% and 96.4% in patients with PSA < 4, 4–10, 10.1–20, 20.1–50 and > 50 ng ml⁻¹ respectively. Older age, smaller prostate volume, larger number of biopsy cores, presence of abnormal DRE finding and higher PSA level were associated with increased risk of prostate cancer detection upon multivariate logistic regression analyses (P < 0.001). Chinese men appeared to have lower prostate cancer detection rates when compared to the Western population. Taking the different risk factors into account, an individualized approach to the decision of TRUS-guided biopsy can be adopted.     

PSA Levels and the Probability of Prostate Cancer on Biopsy

Objectives: Approaches to screening for prostate cancer have continued to be refined since the introduction of prostate-specific antigen (PSA). Since the introduction of PSA, increasing numbers of patients are presenting solely with an elevated PSA, and palpably normal prostate gland. As newer understanding emerges regarding the meaning of an isolated PSA elevation, urologists are becoming more enabled to counsel their patients and project a more accurate prediction of the likelihood of cancer on biopsy. The following will be a review of PSA in determining the presence of cancer on biopsy.Methods: PubMed and Medline literature searches as well as bibliographic reviews of published peer reviewed journals were performed to select articles regarding PSA and screening for prostate cancer. Relevant articles were reviewed and the data summarized as they pertain to interpreting PSA levels and predicting the presence of prostate cancer.Results: Widespread use of PSA for early detection has resulted in clinical stage T1c becoming the most prevalent presenting stage. For values of PSA between 4.0 and 10.0 ng/ml, there exist a 22–27% likelihood of cancer, while those above 10 ng/ml yield up to a 67% chance of cancer. It must be stressed that DRE must be combined with interpretation of PSA as up to 25% of men with prostate cancer have PSA levels within the normal range 0–4 ng/ml.Conclusions: Evaluation of PSA in the context of prostate volume (PSAD), velocity (PSAV), and age-specific reference ranges, percent-free PSA, and predictive nomograms combining values have allowed for more accurate prediction of the likelihood of prostate cancer prior to biopsy.     

African-American race is a predictor of prostate cancer detection: incorporation into a pre-biopsy nomogram

OBJECTIVES: To construct a pre-biopsy predictive model incorporating several clinical variables, including African-American (AA) or Caucasian race, to predict the risk of prostate cancer detection on prostate biopsy, as traditionally AA men have had a higher incidence of prostate cancer than Caucasian men, but previous predictive tools for prostate cancer have not incorporated the effect of race. PATIENTS AND METHODS: We evaluated 9473 patients undergoing initial prostate biopsy at three equal-access healthcare institutes from 1993 to 2003. At each biopsy session, patient age, race, serum prostate-specific antigen level (PSA), digital rectal examination (DRE) findings, number of biopsy cores taken, year of biopsy, and pathological findings were recorded. A logistic regression model was constructed to evaluate predictors of cancer detection based on pre-biopsy variables. The model was internally validated using the bootstrap statistical method, and a nomogram was constructed. RESULTS: Prostate cancer was diagnosed in 1895 (33%) AA men and 991 (26%) Caucasians. AA men had a significantly higher mean serum PSA level than Caucasians, at 13.0 and 8.5 ng/mL, respectively (P < 0.001). The mean ages were similar between AA and Caucasian men (P = 0.23), but Caucasian men had a higher incidence of an abnormal DRE (P < 0.001). On multivariate analysis, age, race, year of biopsy, PSA level, DRE, and number of cores taken were all statistically significant (P < 0.001). Hazard ratios were (controlling for year of biopsy); age (1.30), Caucasian race (0.74), PSA level (1.47), DRE (1.75), and number of cores taken (1.19). The predicted model had a boot-strapped concordance index of 0.75. CONCLUSION: AA race remains an independent predictor of prostate cancer detection in men undergoing initial prostate biopsy. This nomogram is the first to individualise the risk by AA or Caucasian race in a predictive model for counselling men on their probability of having cancer at the time of their first biopsy.     

Pilot study of the practical relevance of a one-step test for prostate-specific antigen in capillary blood to improve the acceptance rate in the early detection program of prostate carcinoma

Objective: Current studies have proven that early,organ-confined stages of prostate cancer can be diagnosed through screening based on PSA levels, thus reducing cancer mortality. Here we report about our experience using an innovative one-step test for PSA in capillary blood. Methods: The incubation time for a 50 μl blood sample with the indicator strip is 12 minutes until the qualitative visual results (<4.0 ng/ml or ≥ 4 ng/ml)appear. In cooperation with urologists and accompanied by an extensive information campaign, the one-step test was made available free of charge to all men between the ages of 45 and 75 in all 28 pharmacies of our city (100,000 inhabitants). Results: The test's acceptance rate among the 2119 participants between the ages of 45 and 75 years amounted to 13.0%. Fifteen percent of all the tests conducted showed a positive PSA result (≥ 4 ng/ml). Prostate carcinoma was histologically confirmed in 14 (0.66%) of the men, nine times in the early stage (T2) and five times in the clinical stage (T3),corresponding to an incidence of circa 650 cases per 100,000 men in the target age group. Conclusions: This newly developed PSA test system can enhance the acceptance rate and effectiveness of medical check-ups for prostate cancer, because it is easy-to-use, cost-effective and accurate (specificity 81.3%, sensitivity 91.1%). The test should be always conducted by an experienced physician. It is not a substitute for a regular physical examination (DRE, TRUS, biopsy...). This revised version was published online in September 2006 with corrections to the Cover Date.     

Predictors of prostate cancer on repeat transrectal ultrasound-guided systematic prostate biopsy

BACKGROUND: We analyzed the outcome of repeated transrectal ultrasound (TRUS)-guided systematic prostate biopsy in Japanese men whose clinical findings were suspected of prostate cancer after previous negative biopsies. METHODS: Between January 1993 and March 2002, 1045 patients underwent TRUS-guided prostate biopsy. Among them, 104 patients underwent repeat biopsy due to indications of persistent elevated serum prostate-specific antigen (PSA), abnormal digital rectal examination (DRE) or TRUS, increased PSA velocity, and/or previous suspicious biopsy findings. Several clinicopathological factors were evaluated for their ability to predict the detection of prostate cancer on repeat biopsy. RESULTS: Prostate cancer was detected in 22 of 104 patients (21.2%) who underwent repeat biopsies. PSA concentration and PSA density at both the initial and repeat biopsies, and PSA velocity in men with positive repeat biopsy were significantly greater than those in men with negative repeat biopsy. The incidence of abnormal findings in DRE and TRUS at initial biopsy in men with positive repeat biopsy was also significantly higher than that in men with negative repeat biopsy. However, neither the presence of prostatic intraepithelial neoplasia nor number of biopsy cores at initial biopsy had a significant association with the results of the repeat biopsy. Furthermore, multivariate analysis revealed that PSA and PSA density at both the initial and repeat biopsies, PSA velocity, and DRE and TRUS findings at initial biopsy were independent predictors of malignant disease on repeat biopsy. CONCLUSION: Despite an initial negative biopsy, repeat TRUS-guided biopsy should be carried out to exclude prostate cancer in cases of suspicious clinical findings, such as elevated PSA or PSA-related parameters, or abnormal findings of DRE or TRUS.