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. 2023 Oct-Dec;11(4):299-304.
doi: 10.4103/sjmms.sjmms_49_23. Epub 2023 Oct 6.

Prostate-specific Antigen Density as a Proxy for Predicting Prostate Cancer Severity: Is There Any Difference between Systematic and Targeted Biopsy?

Mostafa A Arafa  1   2 , Karim Hamda Farhat  1 , Danny M Rabah  1   3   4 , Farrukh K Khan  3 , Alaa Mokhtar  4 , Waleed Al-Taweel  4
Affiliations

Prostate-specific Antigen Density as a Proxy for Predicting Prostate Cancer Severity: Is There Any Difference between Systematic and Targeted Biopsy?

Mostafa A Arafa et al. Saudi J Med Med Sci. 2023 Oct-Dec.

Abstract

Background: Prostate cancer screening with prostate-specific antigen (PSA) can result in unnecessary biopsies and overdiagnosis. Alternately, PSA density (PSAD) calculation may help support biopsy decisions; however, evidence of its usefulness is not concrete.

Objective: To evaluate the predictive value of PSAD for clinically significant prostate cancer detection by systematic and MRI-targeted biopsies.

Methods: This prospective study was conducted at two tertiary hospitals in Riyadh, Saudi Arabia, between December 2018 and November 2021. Patients suspected of prostate cancer were subjected to multi-parametric MRI, and for those with positive findings, systematic and targeted biopsies were performed. Clinically non-significant and significant prostate cancer cases were classified based on histopathology-defined ISUP grade or Gleason score. The PSAD was measured using the prostate volume determined by the MRI and categorized into ≤0.15, 0.16-0.20, and >0.20 ng/ml2 subgroups.

Results: Systematic and targeted biopsies were carried out for 284 patients. The discriminant ability of PSAD is higher in MRI-targeted biopsy compared with systematic biopsy (AUC: 0.77 vs. 0.73). The highest sensitivity (97%) and specificity (87%) were detected at 0.07 ng/ml2 in targeted biopsy. More than half of the clinically significant cases were detected in the >0.2 ng/ml2 PSAD category (systematic: 52.4%; targeted: 51.1%). The CHAID methodology found that the probability of having clinically significant cancer (CSC) in patients with PSAD >0.15 ng/ml2 was more than threefold than that in patients with PSAD ≤0.15 ng/ml2 (64% vs. 20.2%). When considered by age, in PSAD ≤0.15 ng/ml2 subgroup, the percentage of CSC detection rate increased from 20.2% to 24.6% in patients aged ≥60 years.

Conclusion: PSAD has good discriminant power for predicting clinically significant prostate cancer. A cutoff of 0.07 ng/ml2 should be adopted, but should be interpreted with caution and by considering other parameters such as age.

Keywords: Active surveillance; PSA density; advanced prostate cancer; overdiagnosis; prostate-specific antigen; prostatic neoplasm; screening; systematic biopsy; targeted biopsy.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1
Figure 1
The receiver operating characteristic (ROC) for systematic and MRI-targeted biopsy outcome. (a) ROC for detecting CSC cases by systematic biopsy, (b) ROC for detecting CSC cases by MRI-targeted biopsy. CSC – Clinically significant cancer
Figure 2
Figure 2
Chi-square automatic interaction detection decision tree for the detection of clinically significant cancer of cancer prostate. *Other cases included free cases and clinically nonsignificant cases, **Percent relates to the total number of patients (N = 284). CSC – Clinically significant cancer; NCSC – Nonsignificant CSC; PSAD – Prostate-specific antigen density
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