The Chances of Subsequent Cancer Detection in Patients with a PSA > 20 ng/ml and an Initial Negative Biopsy

Transrectal ultrasound (TRUS)–guided prostate biopsy is known to carry a significant false-negative rate, leading some patients to have multiple biopsies. We investigated cancer detection rates in patients with a PSA >20 ng/ml and a negative initial biopsy. We reviewed our database of 2396 TRUS-guided biopsies done between 1997 and 2002 in order to give a follow-up of at least 6 years. PSA, PSA density (PSAD), PSA velocity (PSAV), prostate volume, and DRE findings were analysed in relation to cancer status. Of the patients, 388 (16%) had a PSA >20 ng/ml, including 99 (26%) with benign biopsies. Of those, 67 were rebiopsied, including 19 (28%) with cancer on the first rebiopsy and four (6%) on further biopsies. PSAD, DRE, and volume significantly differed between rebiopsied patients with and without cancer (p <0.05). Patients who present with a PSA >20 ng/ml and have an initial negative biopsy have a high chance of malignancy being detected on a second biopsy. However, if a second biopsy is also negative, then the chances of subsequent biopsies showing signs of cancer are very low if the DRE is normal and particularly if the PSAD is >0.35 ng/ml/cm.