<p><strong>For patients with a PSA > 50 ng/mL and no clinical concerns for infection or other cause for increased PSA (e.g., recent prostate instrumentation), clinicians may omit a prostate biopsy in cases where biopsy poses significant risk or where the need for prostate cancer treatment is urgent (e.g., impending spinal cord compression). (<em>Expert Opinion</em>)</strong></p>
Discussion
Discussion
<p>For patients with a PSA > 50 ng/mL and no evidence of inflammation, infection, recent instrumentation or catheterization, the likelihood of high-grade prostate cancer has been estimated to be as high as 98.5%.<sup>237</sup> Therefore, in situations where biopsy may be risky (e.g., anticoagulation, significant comorbidity, frailty) or delay urgent treatment (e.g., spinal cord compromise from metastases), immediate biopsy can be delayed or omitted. The extremely high risk of prostate cancer should be shared with the patient, and SDM should be used in the decision on whether to omit an immediate prostate biopsy. This recommendation does not exclude the potential to proceed with biopsy or other prostate cancer evaluation, if deemed clinically appropriate. In addition, it does not obviate the need for biopsy at a later time (e.g., required for treatment, insurance, genetic testing). Imaging to establish extent of disease or confirm metastasis may be helpful if an immediate biopsy is not performed.</p>