Future Aspects of Prostate Biopsy – The Use of Primary Circulating Prostate Cells to Select Patients for Prostate Biopsy: Evidence, Utility and Cost-Benefit

False positive rate of serum PSA and implications: Costs, increased follow-up, collateral effects of unnecessary prostate biopsies (including direct, sepsis, hemorrhage y indirect anxiety, increased follow-up)Ideally a screening test should detect all clinically significant prostate cancers and not benign pathologies.It has been normal practice that men who are found to have an abnormal serum PSA level should have a prostate biopsy.For example, the UK Prostate Cancer Risk Management Programme (PCRMP) states "if your PSA is definitely raised, a prostate biopsy is required to determine whether cancer is present" The justification for performing biopsy in men with an abnormal PSA is that they are at high risk of prostate cancer.However, data from the Prostate Cancer Prevention Trial (Thompson, 2006) and Baltimore Longitudinal Study on Aging (Fang, 2001) have demonstrated that prostate cancer is also a common finding on biopsy in men with a normal PSA level.The data from this large study provide a strong argument against the use of an arbitrary PSA threshold to select men for prostate biopsy.The aim of prostate biopsy is not to detect each and every prostate cancer.After all, the Prostate Cancer Prevention Trial demonstrates that the majority of prostate cancers are in men with a normal PSA level.The aim of prostate biopsy is actually to detect those prostate cancers with the potential for causing harm.It has been estimated that, of asymptomatic men in whom prostate cancer is detected by prostate biopsy following PSA measurement, around 50% (Draisma, 2003) do not require active treatment.Men with clinically insignificant prostate cancers that were destined never to cause any symptoms, or affect their life expectancy, may not benefit from knowing that they have the 'disease'.Indeed, the detection of clinically insignificant prostate cancer should be regarded as an (under-recognised) adverse effect of biopsy.In order to identify men who are most suitable for prostate biopsy, there is a need to identify a group at high risk, not just of prostate cancer, but of significant prostate cancer.Several large studies have analyzed the clinical characteristics associated with the finding of higher grade (usually defined as Gleason score ≥7) prostate cancer on biopsy.Factors significantly associated with high grade cancer were: PSA level, smaller prostate volume, abnormal DRE findings, age, and black African and black Caribbean ethnicity, whereas a previous negative prostate biopsy reduced this risk.A false-positive PSA (or a PSA >4.0ng/mL) has consequences, firstly the collateral effects or complications of a prostate biopsy, the additional follow-up and possibility of a second or third biopsy.Observational studies, and theoretical considerations, suggest that rebiopsy will detect prostate cancer in some men with an initially negative prostate biopsy.These studies reported multivariate analyses of predictive factors for positive repeat biopsy but there was disagreement on which factors predict re-biopsy outcome.There is evidence, however, that the odds of high grade prostate cancer are reduced if a man has previously had a negative biopsy.(Djavan, 2000;Eggener, 2005; López-Corona, 2003;Mian, 2002; Roobal, 2006) Using the results from the European Prostate Cancer Detection Study, there were no significant differences found in the tumor characteristics of stage and Gleason score comparing the first and second biopsy.The results have shown that with a second biopsy, www.intechopen.com