Does prostate-specific antigen density alter decision making on biopsy?

Objective: The ability of prostate-specific antigen density (PSAD) to predict prostate cancer in biopsy specimens is evaluated in patients with benign digital rectal examination (DRE) and prostate-specific antigen (PSA) between 4.0 and 10.0 ng/ml. Material and Methods: 144 referred patients with a benign DRE and PSA > 4.0 ng/ml were additionally evaluated by transrectal ultrasonography and transrectal biopsies. PSAD values were calculated and statistical analysis was performed. Results: The mean PSAD value was able to distinguish significantly between benign prostate conditions and prostate cancer in patients with PSA > 4.0 ng/ml. However, in 73 patients with 4.0 < PSA ≤ 10.0 ng/ml no significant stratification was obtained. At a PSAD value of 0.15 the pretest probability of 18% for positive biopsy was lowered to a posttest probability of 8.1% and PSAD appeared to be of limited value regarding sensitivity and specificity at different cutoff values (ROC curve). Applying age-specific reference ranges would have reduced diagnostic procedures for men between 60 and 79 years old with 7.0% without missing prostate cancer. Conclusions: In this study PSAD was shown to have only a moderate additive value in decision making to omit biopsy for the individual patient with benign DRE and PSA between 4.0 and 10.0 ng/ml. Age-specific reference ranges of PSA can prevent unnecessary diagnostic procedures.