Thursday, May 20, 2010

Management of Rising Prostate-Specific Antigen Following a Negative Biopsy

Current Opinion in Urology:
May 2010 - Volume 20 - Issue 3 - p 198–203
doi: 10.1097/MOU.0b013e3283385fbd
Prostate cancer: Edited by Andrew Stephenson

Purpose of review: Most men who undergo prostate biopsy will not be found to have cancer, but a significant number of those men may harbor cancer that was simply not identified. This is especially likely when inadequate biopsy strategies were employed, or when entities associated with a likelihood of underlying cancer such as high-grade prostatic intraepithelial neoplasia or atypia were identified, begging the question of what one means by the term ‘negative biopsy’. There is little consensus on management of this heterogeneous population.

Recent findings: Traditional sextant biopsy may miss half of cancers, and even extended or saturation biopsy protocols miss many small cancers. It is widely assumed but unproven that rising prostate-specific antigen (PSA) following negative prostate biopsy is more likely to indicate cancer than stable or decreasing PSA. Although missing small low-grade cancers might actually allow the patient to avoid overtreatment, some of these cancers are high-grade so identification may offer the ideal scenario for curative therapy.

Summary: Many men with rising PSA following negative biopsy harbor prostate cancer. Thoughtful patient selection with a low threshold for repeat biopsy offers the best opportunity to diagnose clinically significant cancers while still curable without risking over utilization of biopsy.

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