Biopsy Follow-Up of Prostate-Specific Antigen Tests

Background: A prostate-specific antigen (PSA) level above 4 ng/mL has historically been recognized as an appropriate threshold to recommend biopsy; however the risk of high-grade disease observed among men with lower PSA levels in the Prostate Cancer Prevention Trial has led to calls to change the criteria for biopsy referral. Purpose: To aid providers when discussing aggressiveness of biopsy by cataloging available community biopsy patterns and determine whether lower PSA thresholds are being used to recommend biopsy. Methods: Laboratory and biopsy records were reviewed among 59,764 men in a large Washington State health plan between 1998 and 2007. Follow-up in the 12-month period after a test was categorized as biopsy, urology visit without biopsy, additional PSA testing with no urology visit, or no PSA-related follow-up. Data analysis occurred between 2010 and 2011. Results: Twenty-eight percent of tests with PSA levels >= 4.0 ng/mL, 2.9% of tests with levels between 2.5 and 4.0 ng/mL, and 0.4% of tests with levels <2.5 ng/mL were followed with a biopsy within 12 months. More than 40% of elevated tests (>= 4.0 ng/mL) were followed by a urologist visit without a biopsy, and more than 30% of tests >= 4.0 did not have any PSA-related follow-up within 12 months. PSA velocity, defined as annualized rate of change in PSA level, was strongly associated with biopsy, especially when absolute PSA was <4.0 ng/mL. There appear to be no discernable temporal trends in biopsy thresholds or practice patterns based on PSA lower levels or velocity. Conclusions: Despite recent calls to more aggressively recommend biopsy at lower PSA thresholds, the practice in this large health plan has remained consistent over time. (Am J Prev Med 2012;42(1):37-43) Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine