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OBJECTIVE: To determine cut-off values for prostate specific antigen density (PSAD) in diagnosing prostate carcinoma in symptomatic patients. METHODS: This cross sectional, observational study conducted at Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, Pakistan from June 2020 to May 2021. Symptomatic patients (309) having prostatic enlargement on ultrasound were selected through consecutive sampling. All the patients underwent prostate biopsy for histopathological diagnosis. Prostate specific antigen density was calculated and compared between different age groups and different diseases. ROC curve was constructed and area under the curve was calculated to find out cut-off values value for PSAD. Sensitivity, specificity and accuracy were calculated at the cut-off values. RESULTS: Among 309 patients of median age was 68 years (IQR 43 – 75). There was a significant difference of PSAD in different age groups (p

Objective: The objective of the study is to identify the rate of significant prostate cancer (PCa) detection in PI-RADS3 lesions in AA patients stratified by PSAD threshold of < 0.15 vs. ≥ 0.15 ng/ml2 and lesion diameter of < 1 cm vs ≥ 1 cm. Methods: We analyzed our institutional database of MRI-TB to identify the rate of significant prostate cancer (PCa) detection in PI-RADS3 lesions in AA patients stratified by PSAD threshold of < 0.15 vs. ≥ 0.15 ng/ml2 and lesion diameter of < 1 cm vs ≥ 1 cm. Significant prostate cancer was defined as Gleason grade group 2 or higher on MRI-TB of the PI-RADS 3 lesion. Results: Of 768 patients included in the database, 211 (27.5%) patients identified themselves as AAs. Mean age of AA patients was 63 years and mean PSAD was 0.21. Sixty nine (32.7%) AA patients were found to have PI-RADS 3 lesions. Mean PSAD of AA patients with PI-RADS 3 lesions was 0.21 ng/ml2 as well. Fifty percent of AA patients with PI-RADS 3 lesions had PSAD ≥ 0.15 ng/ml2. Significant PCa detection rate for AA patients with PI-RADS 3 lesions was 9% for PSAD of ≥ 0.15 vs. 0.03% percent for AA patients with PSAD < 0.15 ng/ml2 (OR 7.056, CI 1.017–167.9, P = 0.04). Stratification by lesion diameter (< 1 cm vs. > 1 cm) resulted in missing 0% of significant PCa when only AA patients with PSAD ≥ 0.15 ng/ml2 and lesion diameter ≥ 1 cm received MRI-TB. Conclusions: We report on the performance of a reported PSAD density threshold in detecting significant PCa in one of the largest series of AA patients receiving MRI-TB of the prostate. Our results have direct clinical implications when counseling AA patients with PI-RADS 3 lesion on whether they should undergo MRI-TB of such lesions. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the influence of endogenous testosterone density (ETD) on pelvic lymph node invasion (PLNI) in high risk (HR) prostate cancer (PCa) treated with radical prostatectomy (RP) and staged with extended pelvic lymph node dissection (ePLND). Materials and methods: ETD was evaluated as the ratio of endogenous testosterone (ET) on prostate volume (PV). HR-PCa was assessed according to the European Association of Urology (EAU) system. The association of ETD and other routinely clinical factors (BPC: percentage of biopsy positive cores; PSA: prostate specific antigen; ISUP: tumor grade system according to the International Society of Urologic Pathology; cT: tumor clinical stage) with the risk of PLNI was assessed by the logistic regression model. Results: Overall, 201 out of 805 patients (24.9%) were classified HR and PLNI occurred in 42 subjects (20.9%). On multivariate analysis, PLNI was independently predicted by BPC (OR 1.020; 95% CI 1.006–1.035; p = 0.019), ISUP > 3 (OR 2.621; 95% CI 1.170–5.869; p = 0.019) and ETD (OR 0.932; 95% CI 0.870–0.999; p = 0.045). After categorizing continuous clinical predictors, the risk of PLNI was independently increased by ETD up to the median (OR 2.379; 95% CI 1.134–4.991; p = 0.022), BPC > 50% (OR 3.125; 95% CI 1.520–6.425; p = 0.002) as well as by ISUP > 3 (OR 2.219; 95% CI 1.031–4.776; p = 0.042). Conclusions: As ETD measurements decreased, patients were more likely to have PLNI. In HR disease with PLNI, the influence of PCa on ETD should be addressed by higher level studies. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate the efficiency of prostate-specific antigen (PSA) density (PSAD) calculated through prostate volume (PV) obtained via transrectal ultrasound (TRUS) and magnetic resonance imaging (MRI) and actual prostate weight (PW) methods obtained via pathological evaluation on the prediction of biochemical recurrence (BCR) in the follow-ups of patients who had undergone radical prostatectomy (RP).Methods: A total of 335 clinically localized prostate cancer (PCa) patients who had received open RP between January 2015 and December 2018 were enrolled in the study. Pre and postoperative demographic data, clinical and pathological findings and BCR conditions were recorded. The PSAD was calculated using information obtained through preoperative TRUS examinations, MRI, and collected pathological specimens after RP by dividing the maximum preoperative PSA value and PV/PW.Results: In a mean follow-up duration of 20.2 ± 8.5 months, recurrence was observed in 52 patients (24.4%) and progression was observed in 8 (3.8%) patients. The TRUS-PSAD, MRI-PSAD, and PW-PSAD values were statistically significantly higher in BCR patients compared to non-BCR patients. The International Society of Urologic Pathologists (ISUP) grade 5 and pT3b as a pathological stage were detected as independent variables in the prediction of BCR formation. Actual PW had a high prediction value compared to other PSAD measurements at <40 g prostate weights, but it had a low prediction value in prostates with an actual PW >60 g.Conclusions: In this study, it was stated that PSAD acquired through different imaging methods does not affect the usability of PSAD in BCR prediction in clinical practice. The ISUP grade 5 and pT3b stage PCa were detected as independent markers in BCR prediction after RP. [ABSTRACT FROM AUTHOR]

Prostate volume and PSA density (PSAd) are important in the risk stratification of suspected prostate cancer (Pca). PI-RADS v2.1 allows for determining volume via segmentation or ellipsoid calculation. The purpose of our study was to compare ellipsoid and segmentation volume calculation methods and evaluate if PSAd diagnostic performance is altered. We retrospectively assessed 397 patients (mean age/standard deviation: 63.7/7.4 years) who underwent MRI and prostate biopsy or prostatectomy, with Pca classified by Gleason ≥3 + 4 and ≥4 + 4 disease. Prostate total volumes were determined with ellipsoid calculations (TVe) and with semi-automated segmentation (TVs), along with inter-rater reliability with intraclass correlation coefficient (ICC). PSAd was calculated for TVe and TVs and ROC curves were created to compare performance for Gleason ≥3 + 4 and ≥4 + 4 disease. TVe was significantly higher than TVs (p < 0.0001), with mean TVe = 55.4 mL and TVs = 51.0 mL. ROC area under the curve for PSAd derived with TVe (0.63, 95%CI:0.59–0.68) and TVs (0.64, 95%CI:0.59–0.68) showed no significant difference for Gleason ≥3 + 4 disease (p = 0.45), but PSAd derived with TVs (0.63, 95%CI: 0.58–0.68) significantly outperformed TVe (0.61, 95%CI: 0.57–0.67) for Gleason ≥4 + 4 disease (p = 0.02). Both methods demonstrated excellent inter-rater reliability with TVe with ICC of 0.93(95%CI: 0.92–0.94) and TVs with ICC of 0.98(95%CI: 0.98–0.99). Traditional ellipsoid measurements tend to overestimate total prostate volume compared to segmentation, but both methods demonstrate similar diagnostic performance of derived PSA density for PI-RADS clinically significant disease. For higher grade disease, PSAd derived from segmentation volumes demonstrates statistically significant superior performance. Both methods are viable, but segmentation volume is potentially better. • Traditional ellipsoid measurements overestimate prostate volume versus segmentation. • Both methods derived PSA density have similar performance for Gleason >/=7 disease. • Segmentation method for PSA density outperforms ellipsoid for high grade cancer. [ABSTRACT FROM AUTHOR]

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Rationale and Objectives: PSA density (PSAd), an important decision-making parameter for patients with suspected prostate cancer (PCa), is dependent on magnetic resonance imaging prostate volume (PV) estimation. We aimed to compare the accuracy of the ellipsoid and bullet-shaped formulas with manual whole-gland segmentation as reference standard and to evaluate the corresponding PSAd diagnostic accuracy in predicting clinically significant PCa.Materials and Methods: We retrospectively analysed 195 patients with suspected PCa who underwent magnetic resonance imaging and prostate biopsy. Patients with PCa were categorized according to ISUP score. PV and corresponding PSAd were calculated with manual segmentation (mPV and mPSAd) as well as with ellipsoid (ePV and ePSAd) and bullet-shaped (bPV and bPSAd) formulas. Inter and intra-reader reproducibility were assessed with Lin's concordance correlation coefficient and the intraclass correlation coefficient (ICC). A 2-way analysis of variance with post-hoc Bonferroni test was used for assessing PV differences. Predictive values of PSAd calculated with different methods for detecting clinically significant PCa were evaluated by receiver operating characteristic curve analysis and Youden's index.Results: Both intra (ρ = 0.99, ICC = 0.99) and inter-reader (ρ = 0.98, ICC = 0.98) reproducibility were excellent. No significant difference was found between ePV and reference standard (p = 1.00). bPV was significantly different from both (p = 0.00). PSAd (mPSAd/ePSAd cut-off ≥ 0.15, bPSAd cut-off ≥ 0.12) had sensitivity = 69-70%, specificity = 72-75%, areas under the curve = 0.757-0.760 (p = 0.70-0.88).Conclusions: Our work shows that when using bullet-shaped formula, a different PSAd cut-off must be considered to avoid PCa under-diagnosis and inaccurate risk-stratification. [ABSTRACT FROM AUTHOR]

Objective: In this study, we aimed to determine the predictive factor for additional treatment requirement in active surveillance (AS) for patients with low or very low-risk prostate cancer (PCa) and we investigated the effect of tumor burden by total core involvement rate in biopsy to predict of need for additional treatment. Material and methods: 107 patients with PCa in AS between 2005 and 2018 have been evaluated retrospectively. Groups were divided into two groups according to the need for additional treatment. Group 1 received additional treatment, group 2 did not receive additional treatments and active surveillance was continued. Patient's total prostate-specific antigen (tPSA), prostate-specific antigen density (PSA-D), total core involvement count, quantity and rate at biopsy pathology results and follow-up period were recorded and compared in the two groups. Results: The current cohort includes 107 patients. Mean age at diagnosis was 63.01years. Mean tPSA values at diagnosis were 6.09 ng/mL and 5.2 ng/mL in the group 1 and group 2, respectively. Mean follow-up period was 38.1 months (range, 12 to 134 months). Only PSA-D measurement significantly predicted need for additional treatment (p = 0.017). ROC analysis showed that the optimal threshold was 0.13 ng/mL/cc (sensitivity: 70.8%; specificity: 57.1%). Additional treatment requirement was not detected in patients with PSA-D cut-off level less than 0.07 ng/mL/cc. Conclusions: Total tumor burden of less than 5% is safe for patients with low or very low-risk PCa in AS. A 0.13 ng/mL/cc cut-off level of PSA-D can predict to need for additional treatment in patients managed by AS. [ABSTRACT FROM AUTHOR]

Objective: The use of 10–12-core systemic transrectal ultrasound (TRUS)-guided prostate biopsy protocols with extended-sampling has been an optimizing strategy for diagnosis of prostate cancer. In this study, we aim to examine the cancer detection rate (CDR) and the complications following prostate biopsy at our institution. Materials and Methods: We retrospectively reviewed medical data of patients who underwent TRUS-guided prostate biopsy between 2007 and 2013 at our institution. The pathological outcomes, major complications, and morbidities were recorded and assessed clinically. Results: During the study period, 425 patients who underwent TRUS-guided prostate biopsy were enrolled. The mean age of the participants was 67.9 years. Overall, 75 (17.6%) patients were diagnosed with prostate cancer. Cancer was detected in 0% (0/10), 7.0% (15/215), 16.5% (20/121), and 50.6% (40/79) of patients in the subgroups with patient prostate-specific antigen (PSA) 20 ng/ml, respectively. The optimal cutoff values of PSA density were 0.19, 0.29, and 0.78 in the subgroups with patient PSA 4–10 ng/ml, 10–20 ng/ml, and >20 ng/ml. In total, 11 patients had afebrile urinary tract infections (UTI), 9 patients had febrile UTI, and another 2 patients had septic shock after biopsy. The overall incidence of infectious complications was 5.17% (22/425). Other complications were infrequent, consisting only of urinary retention in three patients, hematospermia in two patients, and acute hemorrhagic cerebellar infarction in 1 patient. Conclusion: Our study demonstrated the CDR, the incidence, and type of complications following TRUS-guided prostate biopsy. Further prospective studies are required to determine methods for reducing complications from prostate biopsy.

Introduction: Prostate-Specific Antigen (PSA) is an organ specific rather than cancer specific hormone. It is a single chain glycoprotein produced by epithelial cells of the prostate gland. Role of PSA in carcinoma of prostate is well defined but its role in other diseases of prostate is not very clear. Increased PSA levels are not essentially associated with prostate cancer, but can also be elevated in conditions other than cancerous lesions, such as prostate inflammation, bacterial prostatitis, Benign Prostate Hyperplasia (BPH) and Urinary Tract Infection (UTI). BPH is the most common benign tumours in men with prevalence ranging from 50% for men in their 50s to 90% for men in their 90s. Aim: To find the relation of serum PSA levels with age, Prostate Volume (PV) and PSA density in BPH patients. Materials and Methods: The present hospital-based, crosssectional study was conducted on 162 BPH patients who consulted to the Urology Department of Rajindra Hospital, Patiala and were prescribed to undergo serum PSA evaluation. The serum PSA levels of these patients were estimated by the Enzyme-Linked Immunosorbent Assay (ELISA). Routine investigations included Complete Blood Count (CBC), serum urea, serum creatinine, Fasting Blood Glucose (FBG), serum PSA and ultrasonography of the kidneys, ureter, bladder and prostate. Correlations were evaluated using Pearson correlation coefficient. All the statistical graphs were plotted using Microsoft Excel 2009. The results p-value

Objective: To calculate the negative predictive value (NPV) of negative multiparametric prostate magnetic resonance imaging (mpMRI), accepted as no lesions on images, when combined with prostate-specific antigen density (PSAD) and free/total prostate-specific antigen ratio (f/t PSA) in grey zone patients., Methods: 191 patients with PSA levels between 4-10 mg/mL and negative mpMRI were analyzed. The NPV of negative mpMRI was calculated according to a PSAD level of <0.15 ng/mL/mL, f/t PSA ratio of >0.15, and a combination of both. Patients were divided into three risk groups according to these two parameters, which were PSAD 0.01-0.07 ng/mL/mL and f/t PSA ratio ≥25 in a low-risk group, PSAD 0.08-0.15 ng/mL/mL, and f/t PSA ratio 0.15-0.24 in an intermediate-risk group and high-risk group, in which PSAD > 0.15 ng/mL/mL and f/t PSA ratio <15., Results: NPV of negative mpMRI was 92.6% for clinically significant prostate carcinoma (CSPCa). It increased to 97.5% in a low-risk group and decreased to 33.3% for CSPCa in a high-risk group. NPV of negative mpMRI results were so close when combined with PSAD < 0.15 ng/mL/mL and f/t PSA > 15., Conclusion: f/t PSA ratio might also be used to increase the NPV of mpMRI, like PSAD. We advise not to avoid prostate biopsy when PSAD is >0.15 ng/mL/mL and the f/t PSA ratio is <0.15. However, we need randomized controlled studies with more patients to confirm our study., (Copyright © 2023 AEU. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Multi-parametric magnetic resonance imaging (mpMRI)-directed biopsy for prostate cancer (PC) diagnosis improves the detection of clinically significant prostate cancer (CSPC) and decreases the rate of over-diagnosis of insignificant disease. The aim of this study was to investigate the value of mpMRI combined with prostate specific antigen density (PSAD) in the decision making related to the biopsy. Methods: mpMRI and mpMRI/transrectal ultrasound fusion targeted biopsies with subsequent systematic biopsies were performed in 397 patients (223 biopsy-naïve and 174 with a previous biopsy). Detection rates of (CSPC) and insignificant PC were stratified using the PIRADS score, and the number of avoidable biopsies and missed (CSPC) were plotted against PSAD values of 0.1–0.5 ng/mL2. Results: PIRADS <3 and PSAD <0.2 ng/mL2 were the safest criteria for not performing a biopsy. When applied to the biopsy-naïve group, 21.5% (48/223) of the biopsies could have been avoided and 3.7% (3/82) of CSPC would have been missed. In the repeat biopsy group, 12.6% (22/174) of biopsies could have been avoided and 6.9% (4/58) of (CSPC) would have been missed. Conclusions: A combination of mpMRI and PSAD might reduce the number of biopsies performed with the cost of missing <4% of CSPC. [ABSTRACT FROM AUTHOR]

Objectives: The incidence of prostate cancer is increasing every year, and precision diagnosis and treatment can help reduce unnecessary prostate punctures for prostate cancer patients in the gray area. This study aims to investigate the diagnostic value of 18 F-prostate specific membrane antigen (PSMA) imaging combined with prostate specific antigen (PSA)-derived indicators for gray zone prostate cancer., Methods: A total of 107 patients who underwent 18 F-PSMA PET/CT imaging for suspicious prostate cancer with tPSA of 4 to 10 μg/L (PSA gray zone) in a hospital were retrospectively included, and were divided into a prostate cancer group and a non-prostate cancer group based on pathological findings. Patients underwent PSA testing, 18 F-PSMA, and abdominal ultrasound, and age, tPSA, fPSA, f/tPSA, prostate volume, PSA density (PSAD), maximum standardized uptake value (SUVmax), and molecular imaging prostate specific membrane antigen (miPSMA) score were compared between the 2 groups. Multivariate logistic regression was used to analyze the influencing factors the diagnosis of gray zone prostate cancer. Receiver operating characteristic (ROC) curves were constructed to evaluate the efficacy of PSAD and SUVmax alone and in combination in diagnosing gray zone prostate cancer., Results: The volume of the prostate cancer group [42.00(34.00, 58.00) cm 3 vs 49.00(41.27, 60.41) cm 3 ] was smaller than that of the non-prostate cancer group ( Z =-2.376, P =0.017), and the PSAD [(0.18±0.06) μg/(L·cm 3 ) vs 0.15±0.05 μg/(L·cm 3 )] and SUVmax [18.63(8.03, 28.57) vs 9.33(5.90, 13.52)] were higher than those in the non-prostate cancer group (both P <0.05). The percentage of miPSMA score ≥2 in the prostate cancer group was higher than that in the non-prostate cancer group ( χ 2 =40.987, P< 0.001). PSAD ( OR =22.154, 95% CI 1.430 to 873.751, P =0.042) and SUVmax ( OR =1.301, 95% CI 1.034 to 1.678, P =0.009) were independent influential factors for the diagnosis of prostate cancer in the gray zone. The optimal cut-off values of PSAD and SUVmax were 0.22 μg/(L·cm 3 ) and 8.02, respectively, and the AUCs for the diagnosis of prostate cancer in the gray zone alone and in combination were 0.628 (95% CI 0.530 to 0.720, P <0.05) and 0.806 (95% CI 0.718 to 0.876, P <0.05), 0.847 (95% CI 0.765 to 0.910, P <0.05), with sensitivities of 41.03%, 76.92%, and 74.36% and specificities of 79.41%, 89.71%, and 92.65%, respectively., Conclusions: PSAD and SUVmax are increased in patients with gray zone prostate cancer, and the combination of PSAD and SUVmax is of high value in diagnosing gray zone prostate cancer.

Purpose: Bi-parametric prostate MR (bp-MR) is a valuable tool for detection and characterization of prostate cancer (PCa). Recent studies suggested that PSA-density (PSA-D) in combination with multi-parametric prostate MR as well as bp-MR may achieve a higher diagnostic accuracy than either alone. We aimed to evaluate the diagnostic performance of bp-MR, PSA-D and their combination in biopsy-naïve patients.Methods and Materials: We retrospectively analyzed 334 consecutive patients who underwent prostate MR on a 3T scanner. Only patients (n = 114) who underwent TRUS-biopsy within 30 days following MR with no previous prostate biopsies were considered. Our protocol included T2-weighted and DWI sequences. A Likert score based on PI-RADS v2 was used for bp-MR evaluation. Lesions were graded histopathologically using the ISUP score. We assessed three scenarios: detection of lesions independently of ISUP score (ISUP ≥ 1), detection of both intermediate and clinically significant lesions (ISUP ≥ 2) and detection of clinically significant lesions alone (ISUP ≥ 3). Predictive value of bp-MR and PSA-D was evaluated by ROC curves and logistic regression analysis. A p value < 0.05 was considered statistically significant.Results: In all evaluated scenarios, bp-MR showed a significantly higher predictive power (AUC = 0.87-0.95) compared to the performance of PSA-D (AUC = 0.73-0.79), while their combination (AUC = 0.91-0.95) showed no statistically significant improvement compared to bp-MR alone.Conclusion: Our results confirm that bp-MR is a powerful tool in detection of clinically significant PCa. Contrary to findings in the recent literature, PSA-D does not appear to significantly improve its diagnostic performance. [ABSTRACT FROM AUTHOR]

Racial differences exist in the incidence of prostate cancer (PCa). Although many studies have looked at the performance of prostate-specific antigen (PSA) and PSA density (PSAD) in the detection of PCa, only a few have looked at it in relation to Indonesian men. The objective of this study is to find out better PSA and PSAD cutoff point in the detection of PCa in Indonesian men. Methods: A total of 404 consecutive Indonesian men underwent prostate biopsy for suspicion of PCa from 2008 to 2011. The biopsy criteria include one or more of the following: serum PSA more than 10 ng/mL, PSAD more than 0.15 if PSA 4–10 ng/mL, hypoechoic lesion during transrectal sonography and/or abnormal digital rectal examination. Results: Forty five out of 404 (11.1%) had positive biopsies. The mean age, prostate volume, PSA and PSAD were respectively 64.06 years, 43.03 mL, 45.59 ng/mL and 1.15. Of the 404, 131 cases (32.4%) were confirmed to be urinary retention. Positive urine culture found in 182 cases (45%). The cutoff point to detect PCa as estimated by the receiver operating characteristics was 6.95 ng/mL for PSA (sensitivity 97.8%, specificity 19.6%) and 0.7072 for PSAD (sensitivity 62.2%, specificity 78.7%). Positive predictive value for this PSA and PSAD cutoff point were 11.6% and 27.5% respectively (P=0.004 and P=0.000). There was a significant correlation between hypoechoic lesion and positive biopsy results (P=0.000). Urinary retention elevates PSA cutoff point to 14.55 (sensitivity 90.9%, specificity 50%), while positive urine culture alters almost no PSA cutoff elevation. Conclusions: PSA and PSAD cutoff point for Indonesian men in this series is relatively different from international consensus. Furthermore, these data show that PSA and PSAD cutoff point must be adjusted to racial variation to discriminate between malignant and benign disease. Urinary retention is a significant factor for PSA cutoff increase.

Introduction: Prostate-Specific Antigen (PSA) is an organ specific rather than cancer specific hormone. It is a single chain glycoprotein produced by epithelial cells of the prostate gland. Role of PSA in carcinoma of prostate is well defined but its role in other diseases of prostate is not very clear. Increased PSA levels are not essentially associated with prostate cancer, but can also be elevated in conditions other than cancerous lesions, such as prostate inflammation, bacterial prostatitis, Benign Prostate Hyperplasia (BPH) and Urinary Tract Infection (UTI). BPH is the most common benign tumours in men with prevalence ranging from 50% for men in their 50s to 90% for men in their 90s. Aim: To find the relation of serum PSA levels with age, Prostate Volume (PV) and PSA density in BPH patients. Materials and Methods: The present hospital-based, cross-sectional study was conducted on 162 BPH patients who consulted to the Urology Department of Rajindra Hospital, Patiala and were prescribed to undergo serum PSA evaluation. The serum PSA levels of these patients were estimated by the Enzyme-Linked Immunosorbent Assay (ELISA). Routine investigations included Complete Blood Count (CBC), serum urea, serum creatinine, Fasting Blood Glucose (FBG), serum PSA and ultrasonography of the kidneys, ureter, bladder and prostate. Correlations were evaluated using Pearson correlation coefficient. All the statistical graphs were plotted using Microsoft Excel 2009. The results p-value <0.001 were considered statistically significant. Results: No significant association (p=0.445) between serum PSA and age groups of BPH patients was observed. A significant correlation was observed between serum PSA and PV (r=0.59, p-value <0.001) and PSA density (r=0.56, p-value <0.001) in BPH patients. Conclusion: The present study indicates that there was no association between age specific reference range and serum PSA levels. And PV and PSA density should be considered while interpreting PSA level to improve the diagnostic parameters. [ABSTRACT FROM AUTHOR]

Objective: To find the factors related as predictive factors for Gleason score in prostate cancer patients. Material & methods: This study obtained a total sample of 144 patients with prostate cancer in Sardjito General Hospital Yogyakarta in 2009-2013. Of the total 144 patients, only 64 patients had complete medical records. All patient samples were patients who had biopsy of the prostate. This study is a retrospective case-control study to predict the Gleason Score in patients with prostate cancer in terms of age, total prostate specific antigen (PSA), PSA density and TAUS. Normality test assessed the distribution of the data. Pearson test assessed normal distribution and Spearman test for normal distribution. All data were analyzed using SPSS version 18. Results: Analysis of data from 64 patients with prostate cancer with a normal distribution of the variables obtained on age and TAUS with p > 0.05 whereas abnormal distribution obtained on total PSA, PSA density with p < 0.05. Of the data on the data with a normal distribution, age and TAUS with values obtained p 0.039 and p 0.738. From these data it can be said there is a relationship between age and Gleason score where the higher the age the higher the Gleason score. TAUS of the data can be said there is no relationship between TAUS and Gleason score. Then the abnormal distribution of the data obtained with a total PSA p < 0.001 and PSA density p < 0.001. The data is obtained from the relationship between total PSA and PSA density with Gleason score. Conclusion: It was found that age, total PSA, PSA density affect the increase in Gleason score where the higher the age, total PSA and PSA density the higher the Gleason score in patients.

Objective: In Hasan Sadikin General Hospital Bandung prostate biopsy is recommended for patients with prostate specific antigen (PSA) levels above 10 ng/mL or PSA density (PSAD) above 0.15 if PSA in between 4–10 ng/mL. However, there were other factors beside of prostate cancer (PCa) that could influence PSA value, such as racial differences and prostatitis. Thus, the optimal cut-off point for PSA is still debatable in national level. This research aimed to determine PSA and PSAD cut-off point for patient suspected of PCa in Hasan Sadikin Hospital Bandung. Material & Methods: A total of 502 patients underwent prostate biopsy for suspicion PCa from 2010–2014. The cut-off point of PSA and PSAD is generated from receiver operating characteristic (ROC) curve. Results: The cut-off point for PSA was 14.6 ng/mL (sensitivity 81.4%, specificity 29.8%). The cut-off point for PSAD was 0.23 (sensitivity 81.4%, specificity 34.8%). Positive predictive value (PPV) for this new cut-off point of PSA and PSAD were 41.1% and 37.6% respectively. Conclusion: PSA and PSAD cut-off point for patients in our center was 14.6 ng/mL and 0.23 respectively. This value is relatively higher compared to the Indonesian consensus. The difference might occur due to high rate of urinary tract infection in patients attending Hasan Sadikin General Hospital Bandung.

Introduction: The University of California, San Francisco Cancer of the Prostate Risk Assessment (CAPRA) score is a validated tool using factors at diagnosis to predict prostate cancer outcomes after radical prostatectomy (RP). This study evaluates whether substitution of prostate-specific antigen (PSA) density for serum PSA improves predictive performance of the clinical CAPRA model., Methods: Participants were diagnosed in 2000-2019 with stage T1/T2 cancer, underwent RP, with at least a 6-month follow-up. We computed standard CAPRA score using diagnostic age, Gleason grade, percent positive cores, clinical T stage, and serum PSA, and an alternate score using similar variables but substituting PSA density for PSA. We reported CAPRA categories as low (0-2), intermediate (3-5), and high (6-10) risk. Recurrence was defined as two consecutive PSA ≥ 0.2 ng/mL or receipt of salvage treatment. Life table and Kaplan-Meier analysis evaluated recurrence-free survival after prostatectomy. Cox proportional hazards regression models tested associations of standard or alternate CAPRA variables with recurrence risk. Additional models tested associations between standard or alternate CAPRA score with recurrence risk. Cox log-likelihood ratio test (-2 LOG L) assessed model accuracy., Results: A total of 2880 patients had median age 62 years, GG1 30% and GG2 31%, median PSA 6.5, and median PSA density 0.19. Median postoperative follow-up was 45 months. Alternate CAPRA model was associated with shifts in risk scores, with 16% of patients increasing and 7% decreasing (p < 0.01). Recurrence-free survival after RP was 75% at 5 years and 62% at 10 years. Both CAPRA component models were associated with recurrence risk after RP on Cox regression. Covariate fit statistics showed better fit for standard CAPRA model versus alternate (p < 0.01). Standard (hazard ratio [HR]: 1.55; 95% confidence interval [CI]: 1.50-1.61) and alternate (HR: 1.50; 95% CI: 1.44-1.55) CAPRA scores were associated with recurrence risk, with better fit for standard model (p < 0.01)., Conclusions: In a 2880 patient cohort followed for median 45 months after RP, alternate CAPRA model using PSA density was associated with higher biochemical recurrence (BCR) risk, but performed inferior to standard CAPRA at predicting BCR. While PSA density is an established prognostic variable in prediagnostic settings and sub-stratifying low-risk disease, it does not improve BCR model predictive accuracy when applied across a range of cancer risk., (© 2023 Wiley Periodicals LLC.)

Objective: Prostate specific antigen (PSA) PSA density (dPSA) is a PSA derivative used for increasing the accuracy of PSA. dPSA is calculated by dividing the prostate volume measured with transrectal ultrasonography by the total PSA value. In this study, we evaluated the role of dPSA in the prediction of radical therapy requirement in localised prostate cancer. Materials and Methods: A total of 398 patients, who underwent radical prostatectomy in our department, were included in the study. Preoperative data of the patients (demographic data, total PSA, prostate volume, dPSA and tumor percent IE on biopsy) were evaluated retrospectively. D'Amico risk stratification was performed according to the radical prostatectomy pathological examination. Evaluated parameters were compared between low-risk group (Group 1), who were candidates for active surveillance, and intermediate-high-risk group (Group 2) who were candidates for radical therapies. A dPSA cut-off value was investigated for the prediction of radical therapy requirement for patients with ROC curve analysis. Results: Mean age of the patients was similar between the two groups (62.6±6.6 vs. 62.6±58; p=0.999). PSA (8.9±6.9 vs. 5.5±1.5; p<0.05), dPSA (0.19±0.1 vs. 0.08±0.03; p<0.05) and tumor percent on biopsy (40.8±32.6 vs. 10.7±11.7; p<0.05) were significantly higher in Group 2 when compared to Group 1. ROC curve analysis revealed that patients with a dPSA value higher than 0.10 were more likely to have intermediatehigh- risk disease according to postoperative the D'Amico risk stratification with 71% sensitivity and 86% specificity (AUC=0.782). Conclusion: As a result, it has been shown that a significant portion of patients with a dPSA level of =0.1 was included in the intermediate-highrisk group requiring radical therapies according to the postoperative pathological results. We suggest that predictive models including dPSA would better help decide for active surveillance. [ABSTRACT FROM AUTHOR]

Prostate cancer lesion segmentation in multi-parametric magnetic resonance imaging (mpMRI) is crucial for pre-biopsy diagnosis and targeted biopsy guidance. Deep convolution neural networks have been widely utilized for lesion segmentation. However, these methods fail to achieve a high Dice coefficient because of the large variations in lesion size and location within the gland. To address this problem, we integrate the clinically-meaningful prostate specific antigen density (PSAD) biomarker into the deep learning model using feature-wise transformations to condition the features in latent space, and thus control the size of lesion prediction. We tested our models on a public dataset with 214 annotated mpMRI scans and compared the segmentation performance to a baseline 3D U-Net model. Results demonstrate that integrating the PSAD biomarker significantly improves segmentation performance in both Dice coefficient and centroid distance metric.

Objective: To compare the diagnostic value of u PCA3 m RNA, t PSA, f PSA/t PSA ratio and PASD for prostate cancer with prostate specific antigen(PSA) in diagnostic gray zone. Methods: Prostate biopsy was performed in 200 patients whose t PSA were between 4 ng/m L~10 ng/m L(diagnostic gray zone). Among these patients, 111 of them were diagnosed with benign prostatic hyperplasia(BHP group) and 89 with prostate cancer(PCa group) by pathology. The t PSA and f PSA in serum were measured by chemiluminescence-assay. The volume of prostate was measured by transrectal ultrasound. f PSA/t PSA ratio and PSAD were computed and analyzed.The difference of u PCA3 m RNA, t PSA, f PSA/t PSA ratio and PASD between the PCa group and BPH group were compared, and the area under ROC curve, the sensitivity and specificity were analyzed. Results: The f PSA/t PSA ratio of the PCa group was significantly lower than that of the BPH group. The levels of t PSA, PSAD and PCA3 m RNA were significantly higher in PCa group than in BPH group(both P<0.01). The area under ROC curve of these indexes in descending order was PCA3 m RNA, PSAD, f PSA/t PSA radio and t PSA.When the critical value of PCA3 m RNA and PSAD were 0.27 and 0.15, the sensitivity and specificity of diagnosing PCa were 86.5% and77.5%, 80.9% and 55.9%, respectively. Conclusions: Detection of the u PCA3 m RNA, f PSA/t PSA ratio and PASD can improve the diagnosis of prostate cancer with PSA in diagnostic gray zone, and the value of u PCA3 m RNA in urine was highest for the diagnosis of prostate cancer. [ABSTRACT FROM AUTHOR]

To investigate the utility of prostate specific antigen density for detecting prostate cancer in men with serum PSA levels of 4–10 ng/mL. Between January 2003 and November 2007, 237 men (aged 48–84 years, median 71) with total PSA levels of 4–10 ng/mL participated in a protocol for prostate cancer screening. Eligible patients were recommended for transrectal ultrasonography (TRUS)-guided prostate biopsies after measuring prostate volumes transrectally. The diagnostic value of PSA levels and the free-to-total PSA ratio (f/tPSA), PSA densities (PSAD) were compared using receiver operating characteristic analysis. Prostate cancer was diagnosed in 44 (18.6%) of the 237 men who had biopsies. There were significant differences between the groups in the prostate volumes determined by TRUS, PSAD, PSA levels and f/tPSA, whereas there was no significant difference in patient age. The area under the curve (AUC) of PSA (0.6786) and PSAD (0.717) was similar and significantly greater than that of f/tPSA (AUC 0.329). PSAD was a significantly better indicator of prostate cancer than f/tPSA. The sensitivity and specificity of PSA density at a cutoff of 0.134 ng/mL2 was 90 and 33.7%, respectively. PSAD was a better predictor of prostate cancer in Chinese men with PSA levels of 4–10 ng/mL, especially those who have had prior ultrasound-determined measurements of prostate volume. Our data suggest that different PSAD cutoffs may need to be defined for Chinese. [ABSTRACT FROM AUTHOR]

To investigate the relationship between the clinicopathological stage and serum prostate specific antigen (PSA) concentration and PSA density (PSAD) in patients with prostate cancer. The clinicopathological stage was determined on the basis of a pathological examination and clinical data in 65 prostate cancer patients treated by radical prostatectomy. PSA and PSAD were measured before the operation. The Spearman rank correlation was applied to evaluate the relationship between the clinicopathological stage, serum PSA concentration and PSAD. Patients with higher PSA and PSAD were significantly more likely to have higher clinical stages, a higher Gleason score, positive surgical margins, capsular penetration, and seminal vesicle invasion (each P<0.05). But there was no significant association between PSA and lymph node metastasis ( P=0.053). The levels of serum PSA concentration and PSAD were significantly correlated with the clinical stage ( P<0.05) in the prostate cancer patients. The level of both PSA and PSAD were significantly correlated with the clinical stage ( P<0.05) in the prostate cancer patients. But PSAD may be a more powerful predictor of clinical stage and prognosis than PSA. [ABSTRACT FROM AUTHOR]

Background: This study was undertaken to assess the utility of prostate specific antigen (PSA) and PSA density (PSAD) in discriminating between benign and malignant prostate disease in the Kuwaiti Arab population. Methods: A total of 100 consecutive patients suspected of having prostate cancer because of serum PSA > 4 ng/ml, or detection of a prostatic nodule on rectal examination were further investigated by determination of PSAD, TRUS of prostate, sexant prostatic biopsy and histological analysis to establish the correct diagnosis. Other diagnostic measures included the determination of the area under the receiver operating characteristic (ROC) curve, sensitivity and specificity. Results: Of the 100 prostate biopsies that were performed, 33 cases were confirmed to be prostate cancer and 67 were described as benign lesions comprising benign prostatic hyperplasia (BPH) with or without prostatitis. The age range for patients with prostate cancer was 42–90 years, and 52–90 years for those without prostate cancer. The mean prostate volume was 58.82 cc (range 9–177 cc) and 62.60 cc (range 15–140 cc), the mean PSA value was 36.65 ng/ml (range 5.8–200 ng/ml) and 16.49 ng/ml (range 1.4–46.0 ng/ml), while the mean PSAD was 0.92 (range 0.046–5.714) and 0.452 (range 0.034–2.294) for patients with prostate cancer and patients without prostate cancer respectively. Patients with PSA less than 4 ng/ml (3 cases) all had benign prostate lesions, and 7 cases with PSA more than 50 ng/ml all had prostate cancer and were excluded because values above 50 ng/ml have close to 100% specificity for prostate cancer. Further analysis was done on the remaining 90 cases which were patients with a PSA between 4 and 50 ng/ml. The discriminating power of serum PSA for detecting prostate cancer as estimated by the area under ROC was 0.686 while that for PSAD was 0.732. The maximum likelihood for a positive PSA was at a PSAD cut-off point of 0.32. For the PSA cut-off point of l0 ng/ml, the sensitivity was 80%, and specificity was 42.2%. For the PSAD cut-off point of 0.32, the sensitivity was 58% and the specificity 76.6%. Conclusions: Determination of PSAD is not a useful adjunct to serum PSA values in the range of 10–50 ng/ ml in our population. PSAD value less than 0.32 with PSA less than l0 ng/ml strongly suggests benign disease. [ABSTRACT FROM AUTHOR]

To investigate retrospectively whether the eight-core biopsy method improves the prostate cancer detection rate when compared with the standard sextant biopsy method in patients with prostate specific antigen (PSA) levels of 4.1–10 ng/mL. Of 437 patients whose PSA levels ranged from 4.1 to 10 ng/mL, 237 underwent a transrectal ultrasound guided sextant biopsy (sextant group), and 200 underwent an eight-core biopsy (eight-core group). Eight core samples were obtained from each of the far lateral regions in addition to the standard sextant biopsy cores. None of the patients had a previous history of prostate biopsy. Of the 237 patients in the sextant group, prostate cancer was detected in 47 patients (19.8%) and in 50 of the 200 patients in the eight- core group (25.0%). The rates of detection in the two methods were not statistically significant. However, in patients whose PSA density was less than 0.1 ng/mL per cc, the cancer detection rates in the sextant group and the eight-core group were 4.5% and 18.8%, respectively ( P = 0.046). The morbidity and complications of the eight-core biopsy method were not notable. Only in patients with PSA levels of 4.1–10 ng/mL and density of less than 0.1 ng/mL per cc was the eight-core biopsy method an improvement on the sextant biopsy method in terms of prostate cancer detection rate. Accordingly, a number of cores greater than eight will be required to improve the cancer detection rates in patients with PSA levels of 4.1–10 ng/mL and PSA densities of more than 0.1 ng/mL per cc. [ABSTRACT FROM AUTHOR]

Objectives To determine: (i) whether the accuracy of prostate-specific antigen (PSA) density is improved by using the transition zone (TZ) volume instead of total prostate volume, with the γ-seminoprotein (γSP, a measure of free PSA) to total PSA ratio, for detecting prostate cancer; and (ii) to assess the influence of prostate volume on PSA density and γSP/PSA ratio. Patients and methods From April 1995 to July 1997, 297 consecutive patients (46–88 years old) were examined; all had intermediate serum PSA levels (4–10 ng/mL) and/or abnormal findings on digital rectal examination. All patients underwent transrectal ultrasonography (TRUS)-guided biopsy, and the prostate and TZ volumes determined from TRUS. The PSA density relative to the total prostate volume (PSAD) and to the TZ volume (PSAT) were then calculated. The total PSA and γSP levels were measured before the diagnostic procedures. Results Of the 297 patients, 62 (21%) were histologically confirmed to have prostate cancer by biopsy. The area under the receiver operating characteristic curve was 0.680 for PSA, 0.684 for PSAD, 0.764 for PSAT, 0.748 for γSP/PSA, 0.885 for γSP/PSA in patients with a prostate volume <40 mL, while it was 0.817 for PSAT in patients with a prostate volume of ≥40 mL. Using a PSAT threshold of 0.17 in patients with a prostate volume of 40 mL, the number of biopsies was reduced by 56% (66 of 118) and 22 of the 25 cancers (88%) were detected. In addition, a γSP/PSA ratio threshold of 40% in patients with a prostate volume of <40 mL decreased the number of biopsies by 75% (88 of 117) and detected 32 of the 37 cancers (87%). Conclusions Prostate volume was significantly and positively correlated with γSP/PSA and negatively correlated with PSAT. Among patients with a PSA level of 4–10 ng/mL, a low γSP/PSA was most useful for detecting prostate cancer when the prostate volume was <40 mL and a high PSAT was useful... [ABSTRACT FROM AUTHOR]

Background: Whether men with Gleason 3+4 prostate cancer are appropriate active surveillance (AS) candidates remains a matter of debate., Objective: to evaluate the effects of initial Gleason grade 3+3 or 3+4 on clinical outcomes during AS., Design, Setting, and Participants: We retrospectively reviewed outcomes for men on AS between 1990 and 2016 with Gleason 3+3 or 3+4 who had two or more biopsies., Outcome Measurements and Statistical Analysis: We evaluated associations of diagnostic grade with reclassification (upgrade ≥ 3+4), treatment, metastasis, adverse surgical pathology, and biochemical recurrence (BCR) after deferred radical prostatectomy (RP), with a sensitivity analysis for the amount of pattern 4 disease., Results and Limitations: Of 1243 men, 1119 (90%) had Gleason 3+3 and 124 (10%) 3+4 on initial biopsy. The 5-yr unadjusted reclassification-free survival was 49% regardless of grade, while patients with Gleason 3+4 had lower treatment-free survival (49% vs 64%; p<0.01). On multivariate Cox analysis, grade was associated with lower risk of reclassification (hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.46-0.95) and higher risk of treatment (HR 1.37, 95% CI 1.01-1.85). After RP, patients starting with Gleason 3+4 had lower unadjusted 2-yr BCR-free survival (69% vs 93%; p=0.01) and a higher risk of recurrence (HR 3.67, 95% CI 1.30-10.36). Grade was not associated with metastasis (<1% at 5 yr) or adverse pathology. In sensitivity analyses, a single high-grade core was associated with lower risk of reclassification and multiple high-grade cores were associated with a higher risk of treatment. The number of high-grade cores was not independently associated with BCR. Limitations include selection bias, a limited number of intermediate-risk patients, and length of follow-up., Conclusions: Gleason 3+4 at diagnosis was associated with risk of reclassification, treatment, and BCR. The number of high-grade cores may help in stratifying men with Gleason 3+4 disease., Patient Summary: Some men with Gleason 3+4 prostate cancer may be appropriate surveillance candidates, but longer follow-up and evaluation of more patients are necessary., (Copyright © 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To investigate the preliminary applicability of Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) score in the condition of 3.0T multi-parametric magnetic resonance imaging (Mp-MRI) combined with clinical classic indicators for the diagnosis of prostate cancer (PCa). Methods: The clinical and MRI materials of 247 patients of suspicious prostate disease treated in Second Affiliated Hospital of Soochow University from June 2015 to November 2016 were analyzed retrospectively, including 110 cases with PCa and 137 cases without cancer.All cases underwent the high-resolution axial T(2)-weighted imaging (T(2)WI), diffusion weighted imaging (DWI) and dynamic contrast enhancement-magnetic resonance imaging (DCE-MRI) and were confirmed pathologically by puncture biopsies.The Mp-MRI materials of all cases were scored according to PI-RADS v2.The prostate volume and prostate specific antigen (PSA) density (PSAD) value were calculated according to the formulas.The univariate and multivariate analysis were performed for the observed indicators (age, prostate volume, PSA, PSAD and PI-RADS v2 score) to determine the independent predictors for PCa.Then, a Logistic regression model (combined prediction model) was established by the independent predictors for combined diagnosis of PCa.The receiver operating characteristic curve (ROC) curve analysis was performed to get the sensitivity and specificity of each independent predictor and the model to diagnose PCa.The differences of AUC values of each independent predictor and the model were compared with each other to evaluate the diagnostic performance for PCa. Results: The differences in the age, prostate volume, PSA, PSAD and the PI-RADS v2 score between patients with PCa and non-cancer group were all statistically significant ( t =2.870, Z =-4.230, -7.787, -9.477, -10.826, all P <0.05). The PSAD and PI-RADS v2 score were independent predictors for PCa ( OR =3.331, 10.546, both P <0.05). The Logistic regression combined prediction model by PI-RADS v2 score and PSAD to forecast PCa was Logit( P )=-5.097+ 2.309×PSAD+ 1.214×PI-RADS v2 score.The area under the curve (AUC) of ROC in the combined model (0.911) was higher than that in the PI-RADS v2 score (0.886) and PSAD (0.851) and the differences were all statistically significant ( Z =2.416, 2.716, both P <0.05); but the difference in the AUC value between PI-RADS v2 score and PSAD was not statistically significant ( Z =1.191, P =0.234). The diagnostic sensitivity of PSAD, PI-RADS v2 score and the model were: 0.891, 0.782 and 0.855, respectively; the specificity were 0.449, 0.912 and 0.847, respectively on their positive thresholds (0.15 μg·L(-1)·ml(-1,) 4 and -0.82). Conclusion: PI-RADS v2 score combined with PSAD in diagnosing PCa is superior to the single application of them and it can lead to high diagnostic sensitivity and specificity for PCa.

Objective: As a definite diagnosis of prostate cancer, puncture biopsy of the prostate is invasive method. The aim of this study was to evaluate the value of OPSAD (the ratio of PSA to the outer gland volume of prostate) as a non-invasive screening and diagnosis method for prostate cancer in a select population., Methods: The diagnosis data of 490 subjects undergoing ultrasound-guided biopsy of the prostate were retrospectively analyzed. This included 133 patients with prostate cancer, and 357 patients with benign prostate hyperplasia (BPH)., Results: The OPSAD was significantly greater in patients with prostate cancer (1.87 ± 1.26 ng/ml(2)) than those with BPH (0.44 ± 0.21 ng/ml(2)) (P < 0.05). Receiver operating characteristic (ROC) curve analysis revealed that the performance of OPSAD as a diagnostic tool is superior to PSA and PSAD for the diagnosis of prostate cancer. In the different groups divided according to the Gleason score of prostate cancer, OPSAD is elevated with the rise of the Gleason score., Conclusion: OPSAD may be used as a new indicator for the diagnosis and prognosis of prostate cancer, and it can reduce the use of unnecessary puncture biopsy of the prostate.

Purpose: We compared the effectiveness of PCA3 (prostate cancer antigen 3) and select comparators for improving initial or repeat biopsy decision making in men at risk for prostate cancer, or treatment choices in men with prostate cancer., Materials and Methods: MEDLINE®, EMBASE®, Cochrane Database and gray literature were searched from January 1990 through May 2012. Included studies were matched, and measured PCA3 and comparator(s) within a cohort. No matched analyses were possible. Differences in independent performance estimates between PCA3 and comparators were computed within studies. Studies were assessed for quality using QUADAS (Quality Assessment of Diagnostic Accuracy Studies) and for strength of evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria., Results: Among 1,556 publications identified, 34 observational studies were analyzed (24 addressed diagnostic accuracy and 13 addressed treatment decisions). Most studies were conducted in opportunistic cohorts of men referred for procedures and were not designed to answer key questions. Two study biases (partial verification and sampling) were addressed by analyses, allowing some conclusions to be drawn. PCA3 was more discriminatory than total prostate specific antigen increases (eg at an observed 50% specificity, summary sensitivities were 77% and 57%, respectively). Analyses indicated that this finding holds for initial and repeat biopsies, and that the markers were independent predictors. For all other biopsy decision making comparisons and associated health outcomes, strength of evidence was insufficient. For treatment decision making, strength of evidence was insufficient for all outcomes and comparators., Conclusions: PCA3 had a higher diagnostic accuracy than total prostate specific antigen increases, but strength of evidence was low (limited confidence in effect estimates). Strength of evidence was insufficient to conclude that PCA3 testing leads to improved health outcomes. For all other outcomes and comparators, strength of evidence was insufficient., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)