What is your opinion on the relevance of Prostate specific antigen density in screening patients with indeterminate PSA?
PSA density is one of several predictive factors in deciding whether to biopsy a patient, with age-related PSA thresholds as the most common factor. If your ultrasound imaging is of good quality, you might calculate transition zone PSA density, which is a better predictor of significant prostate cancer than PSA divided by the entire prostate volume.
Usually, neither the prostate volume nor transition zone volume is known at the time of consultation for an elevated or suspicious PSA. We repeat the PSA at least 3 months after the initial value to make sure the elevated value wasn't due to lab variation and to check whether it is increasing. We find the % free PSA value to be as good if not better predictor than PSA density of significant cancer, so your lab should be reporting those values as well.
PDA density is meant to improve the specificity of PSA in detection of Ca prostate. In ny clinical opinion it's yield is more in larger volume size of prostate in determining between BPH n Ca prostate..If density is like more tHan 0.15 it warrants Biopsy, checking the other confounders of raised PSA
You are correct that prostate cancer is less common in larger prostates, but a large prostate should not disqualify a man from biopsy. We began offering saturation transperineal biopsies as a service to our urology colleagues 10 years ago because the approach was identical to our permanent seed prostate brachytherapy procedures that we have been doing for 20 years. We have many publications on the technique where the average number of biopsy cores is ~ 55 per patient. Although most patients referred to us have had one or more negative transrectal biopsies, our mapping biopsies identified cancer in 770/1362 patients (57%). For men with prostates larger than 100 cm³, the positive yield was lower, 23/96 (24%). Of the 23 positive, 15 had significant disease and 8 had insignificant disease for which active surveillance was recommended.
THE ROLE OF PSA DENSITY IS MINIMAL IN THE ERA OF SATURATION BIOPSY.
THE TOTAL PSA:FREE PSA RATIO IS MORE RELEVANT.
Prostate cancer is less common in larger prostates. PSA density is one of several predictive factors in deciding whether to biopsy. If density is like more than 0.15 - requires Biopsy. We find the % free PSA value to be as good predictor of significant cancer.
I agree with Dr Salem that the role of PSA density is very less in clinical practice.
In a patient with suspiciously raised PSA with normal DRE, my algorithm would be:
- Repeat PSA after antibiotic treatment (if Prostatitis is suspected)
- Free and Total PSA
- PSA velocity if prior PSA reports are available.
- Discuss the option of prostate biopsy with the patient.
The problem with PSA density is that it relies too heavily on ultrasonographic and TRUS measurements which may not be very correct always.
PSADensity is not definitives.percent of free PSA to total PSA and DRE and TRUS are more definitive and helpfull for deciding to biopsy.
The role of PSA density is minimal in the era of saturation biopsy.
The total PSA: free PSA ratio is more relevant.
You should try diffusion MRI. DOI: 10.1002/mrm.26340 and many other references.
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