What criteria should I use to determine whether to refer a patient for prostate biopsy?

To determine whether to refer a patient for a prostate biopsy, the primary criteria revolve around the findings from a multiparametric MRI (mpMRI) and subsequent clinical assessment, especially after an initial referral for suspected prostate cancer ¹.

• Initial Investigation: For people with suspected clinically localised prostate cancer, multiparametric MRI is offered as the first-line investigation, with results reported using a 5-point Likert scale ¹.
• Biopsy Based on mpMRI Likert Score:
  • Likert Score 3 or More: Offer multiparametric MRI-influenced prostate biopsy to people whose Likert score is 3 or more ¹.
  • Likert Score 1 or 2: Consider omitting a prostate biopsy for people whose multiparametric MRI Likert score is 1 or 2 ¹. This decision should be made after discussing the risks and benefits with the person and reaching a shared decision ¹. If the person opts to have a biopsy, offer systematic prostate biopsy ¹.
• Factors for Shared Decision-Making: When discussing the options for MRI or prostate biopsy, help people decide by discussing their prostate-specific antigen (PSA) level, digital rectal examination (DRE) findings (including prostate size estimate), any comorbidities and risk factors (such as increasing age and Black African–Caribbean family background), and any history of a previous negative prostate biopsy ¹. It is important to explain the risks (including the increased chance of being diagnosed with clinically insignificant prostate cancer) and benefits, providing adequate time for their decision ¹.
• Criteria for Biopsy After Negative MRI or Previous Negative Biopsy:
  • Negative Biopsy with Likert Score 3 or More: For people with a negative biopsy who have an MRI Likert score of 3 or more, discuss the possibility of significant disease in a urological cancer multidisciplinary team (MDT) meeting with a view to repeating the prostate biopsy ¹.
  • Raised PSA and Likert Score 1 or 2 (No Prior Biopsy): For people with a raised PSA and MRI Likert score of 1 or 2 who have not had a prostate biopsy, repeat the PSA test at 3 to 6 months ¹. Offer a prostate biopsy if there is a strong suspicion of prostate cancer (e.g., PSA density greater than 0.15 nanogram/ml/ml or PSA velocity greater than 0.75 nanogram/ml/year, or strong family history), taking into account their life expectancy and comorbidities ¹.
  • Raised PSA, Likert Score 1 or 2 (or Contraindication to MRI), and Negative Biopsy: For people with a raised PSA, an MRI Likert score of 1 or 2 (or a contraindication to MRI), and a negative biopsy, repeat the PSA at 3 to 6 months ¹. Offer a prostate biopsy if there is a strong suspicion of prostate cancer (e.g., PSA density greater than 0.15 nanogram/ml/ml or PSA velocity greater than 0.75 nanogram/ml/year, or strong family history), considering their life expectancy and comorbidities ¹.
  • Negative First Biopsy with Risk Factors: A core member of the urological cancer MDT should review the risk factors of all people who have had a negative first prostate biopsy ¹. The risk of prostate cancer is slightly higher if the biopsy showed high-grade prostatic intra-epithelial neoplasia (HGPIN), atypical small acinar proliferation (ASAP), or an abnormal DRE ¹.
• Situations Where Prostate Biopsy is Not Routinely Offered:
  • Do not automatically offer a prostate biopsy based on serum PSA level alone ¹.
  • If clinical suspicion of prostate cancer is high due to a high PSA value and evidence of bone metastases, do not offer prostate biopsy for histological confirmation unless needed as part of a clinical trial ¹.
  • Do not offer mapping transperineal template biopsy as part of an initial assessment, unless as part of a clinical trial ¹.