Which Patients with Negative Magnetic Resonance Imaging Can Safely Avoid Biopsy for Prostate Cancer?

Abstract

PurposeTo determine if there is a sub-set of men who can avoid prostate biopsy (PBx), based on multi-parametric MRI (mpMRI) and clinical characteristics. Materials and MethodsOf 1,149 consecutive men undergoing PBx (10/2011–03/2017), 135 had a pre-biopsy negative mpMRI (Prostate Imaging-Reporting and Data System score<3). Detection rates of clinically-significant prostate cancer (CSPCa) were evaluated according to PSA density (PSAD) and prior biopsy history. CSPCa was defined as Grade Group ≥ 2. Multivariable logistic regression analysis was performed to identify predictors for non-CSPCa on biopsy. ResultsPCa and CSPCa detection rates were 38% and 18%, respectively. Men with biopsy-detected CSPCa had smaller prostates (p=0.004), higher PSAD (p=0.02) and no history of prior negative biopsy (p=0.01) compared to the non-CSPCa cohort. PSAD<0.15ng/mL/cc (p<0.001) and prior negative biopsy (p=0.005) were independent predictors of absence of CSPCa on biopsy. Negative predictive value of mpMRI for biopsy-detection of CSPCa improved with decreasing PSAD, primarily in men with prior negative biopsy (p=0.001), but not for biopsy-naïve men. Thirty-two percent of men had the combination of negative mpMRI, PSAD<0.15ng/mL/cc and negative prior biopsy; none had CSPCa on repeat biopsy. Incidence of biopsy-identified CSPCa in men with negative mpMRI only; men with negative mpMRI and PSAD<0.15ng/mL/cc; and men with negative mpMRI, PSAD <0.15ng/mL/cc and negative prior biopsy was 18%, 10% and 0%, respectively. ConclusionWe propose a sub-set of men (with negative mpMRI, PSAD<0.15ng/mL/cc and prior negative biopsy) who may safely avoid re-biopsy. Conversely, PBx should be considered in biopsy-naïve men, regardless of negative mpMRI, particularly those with PSAD>0.15ng/mL/cc.