With prostate cancer screening and biopsy, the aim is to detect clinically significant prostate cancer (csPCa) and avoid intervening in patients with more indolent or clinically insignificant disease. It is important to screen only those who stand to benefit, such as individuals who are in good general health with a good life expectancy.

Further, there should be conversations with patients about the risks and benefits of simply getting a prostate-specific antigen (PSA) test. Repeat testing is needed to confirm PSA elevation. While you could proceed directly to biopsy in men with an elevated PSA, there is a movement toward biopsying only those who are likely to have csPCa, based on biomarkers and/or imaging. These include blood tests such as 4Kscore (BioReference Laboratories) and the Prostate Health Index or urine tests such as ExoDX (Exosome Diagnostics, Inc), in addition to magnetic resonance imaging (MRI). There is increasing evidence that using biomarkers first can also help to better identify those who are most in need of a biopsy. An MRI will not only help to identify those who are most likely to have csPCa but also will allow for a “targeted” biopsy, reducing the risk that you could miss significant cancer. However, a negative MRI has a negative predictive value of approximately 85%, so you would not want to rely on an MRI to decide not to biopsy. The use of PSA “density” and the biomarkers noted above help in such patients.

As to the approach, most patients still have a transrectal ultrasound–guided biopsy with or without fusion technology. Although the transperineal approach has several advantages over the transrectal approach in terms of the risk of severe infection and a higher yield, it is more uncomfortable for patients. Some individuals find it challenging under local anesthesia, so the transperineal approach is often done in the operating room under sedation or even anesthesia.

Experience remains crucial for both the urologist who is performing the biopsy and the radiologist who is reading the MRI. The radiologist’s experience comes into play in reading the multiparametric MRI and scoring the lesions. Data presented at AUA2021 showed that having a central reviewer changed the interpretation of the MRI in more than half of patients, resulting in higher rates of csPCa detection at biopsy (abstract MP05-12).. Even at high-volume centers, there is quite a bit of variation in the readings. Familiarity with the approach and experience in performing these biopsies are also important. It is possible that the use of MRI fusion technology will compensate for less experience, and that is the subject of some of our research right now.

Combined biopsy, with both MRI-targeted biopsy and systematic biopsy, can detect more csPCa, but it may not always be necessary. One notable study at AUA2021 explored MRI-targeted, systematic, and combined biopsy strategies in relation to the Prostate Imaging Reporting and Data System (PI-RADS) scoring (abstract MP05-17). The benefits of combined biopsy were observed largely in men with PI-RADS 3-4 lesions. The investigators suggested that using targeted biopsy for only PI-RADS 5 cases and combined biopsy for only PI-RADS 3-4 cases might help to avoid excess biopsies in PI-RADS 5 men while maintaining a low risk of missing csPCa. Of course, this must be demonstrated in a large cohort of patients at multiple institutions, but it was an interesting finding.