The continuing saga of the value of PSA velocity

An analysis of data from the Rotterdam and Göteborg subsets of men enrolled in the European Randomized Screening for Prostate Cancer (ERSPC) study suggests that PSA velocity is of little value in the identification of men who would benefit from a second biopsy after a first, negative biopsy.

Vickers et al. identified 1,837 men who participated in the Göteborg or the Rotterdam cohorts of the ERSPC and who had at least one additional prostate biopsy after an initial negative biopsy finding. Their objective was to assess whether PSA velocity could improve the predictive accuracy of a repeat biopsy in such men by comparison with PSA level alone.

According to their data:

  • 363/2,579 repeat biopsies (14%) were positive for prostate cancer.
  • 44/2,579 repeat biopsies (1.7%) were positive and demonstrated a Gleason score ≥ 7.
  • PSA velocity was statistically associated with cancer risk but the predictive accuracy was low (AUC 0.55, p <0.001).
  • PSA velocity improved AUC compared to PSA level alone for high grade cancer.
  • The small increase in risk associated with high PSA velocity was of questionable clinical relevance.
The authors conclude that men who have had a first negative biopsy are at reduced risk for prostate cancer on subsequent biopsies, and that a finding of high grade prostate cancer in  such men is unusual. The also state that, “We found little evidence to support prostate specific antigen velocity to aid in decisions about repeat biopsy for prostate cancer.”
In considering the results of this paper, it is worth noting some of the points made by the authors in their discussion of their findings:
  • Their hypothesis had initially been that PSA velocity would, in fact, predict the outcome of subsequent biopsies in man who had had a first negative biopsy.
  • They do not discount the value of informal consideration of PSA velocity in deciding whether a second biopsy would be of value.
  • They note that in their analysis a dramatic increase in PSA was more likely to indicate benign prostatic hyperplasia than cancer.
  • PSA velocity was slightly more likely to predict for a positive repeat biopsy result showing high grade disease in men tested every 4 years (the Rotterdam group) that in those tested every 2 years (the Göteborg group), but the clinical significance of this result was questionable.

The “New” Prostate Cancer InfoLink is increasingly convinced that the value of PSA velocity as a predictor of the need for biopsy is small. While there may be a select group of patients in whom one can demonstrate a correlation between PSA velocity and probability of a positive biopsy result, for the vast majority of patients the PSA level at a point in time (along with the patient’s age and family history) is a more than adequate predictor of the likelihood of a positive biopsy.

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