<p><strong>In patients with indications for a repeat biopsy who do not have a suspicious lesion on MRI, clinicians may proceed with a systematic biopsy. (<em>Conditional Recommendation; Evidence Level: Grade B</em>)</strong></p>
Discussion
Discussion
<p>Repeat biopsy should be used judiciously after an initial negative biopsy, as repeat biopsy detects fewer and less lethal cancers. Medicare data show 38% of patients with an initial negative biopsy of the prostate undergo a repeat biopsy within 5 years, and the percentage of positive biopsies falls from 34% for the first biopsy to 25% for the second.<sup>290</sup> Nevertheless, many patients have indications for repeat biopsy. Factors that may identify patients likely to have clinically significant prostate cancer after a negative biopsy and a negative MRI include a PSA density > 0.15 ng/mL,<sup>291</sup> a PHI density value > 0.44,<sup>292</sup> or a PSA velocity of 0.27 ng/mL/year or greater.<sup>293</sup> MRI can be an important factor in the decision to perform a repeat biopsy, although a meta-analysis of 29 eligible studies with 8,503 participants<sup>294</sup> suggested mpMRI misses 13% of all cancers. Thus, if a patient has sufficient risk of GG2+ cancer with a negative prostate MRI, clinicians may proceed with systematic biopsy.</p>