Deciding whom to biopsy

Biopsy results from the Prostate Cancer Prevention Trial (PCPT) showed that prostate cancer exists at all PSA levels and that a significant number of men with "normal" PSA levels have high grade cancer. These findings and the low specificity of total PSA in discriminating cancer from benign disease have added to the debate about how best to use PSA in selecting men for prostate biopsy. Lower PSA thresholds for consideration of biopsy, particularly in younger men, are advocated by some. PSA velocity measurements may assist in the identification of men most likely to harbor cancer, and lower PSA velocity thresholds may be more appropriate in younger men. A more individualized approach using a predictive model developed from PCPT biopsy results is promoted by others. While able to incorporate risk variables other than PSA, including new markers, this risk calculator does not include PSA velocity since this variable was not found to have independent predictive value in this model. This article will present differing viewpoints on selecting men for prostate biopsy, one advocating the use of a PSA cut-off or PSA velocity measure (Dr. Catalona) and the other arguing for the routine use of established risk nomograms (Dr. Klein).