High PSA Velocity vs Prostate Cancer: To Biopsy or Not to Biopsy?

Argh!  I hate controversy!  Give me a clean, straightforward answer.  Unfortunately, medicine isn't like that.  We continue to refine our understanding as we gain more knowledge.  We can only make predictions based upon what we know today, not what we may know in the future.  As I've said many times before, our crystal ball is in the shop (at least mine is).

Therefore, it was with some irony that on the same day that I heard back from a close colleague/friend/relative that his prostate biopsy came back negative, the same diagnostic procedure for which I pushed mightily given his rather dramatic & persistently increasing PSA velocity, the Journal of the National Cancer Institute published a study that prostate biopsies performed due to PSA velocity alone did not improve accuracy of diagnosis in a group of 5,519 men.  I wish I'd known that over the last 2 months as I worried about the sudden increase in his PSA that was not amenable to an empiric trial of antibiotics.

Their conclusion was that using PSA velocity as the sole indication for prostate biopsy in the setting of low PSA and normal digital rectal exam lead to one in seven men (more typically, only one in twenty men) being biopsied without statistically significantly increasing the chances of finding a high-grade cancer (Gleason score of 7 or greater) and/or clinically significant cancer (using Epstein criteria).

Their conclusion goes against both the National Comprehensive Cancer Network (you first need to register for free) and the American Urological Association's guidelines.  This controversy and lack of clarity is why medicine is such a difficult profession to undertake, especially in our litigious society.  We're damned if we do and damned if we don't.  Helping a patient make an informed decision based upon our current scope of knowledge isn't enough.  We are expected to be correct 100% of the time, yesterday (in the shortest period of time) and tomorrow, while consuming the least possible resources, after which we receive (threats of) declining reimbursements.  We're being pecked from all sides.  No wonder we're sitting ducks for the malpractice lottery.