How can we predict the active surveillance candidates meeting all Epstein criteria prior to prostate biopsy to avoid overdiagnosis?

Objective: To investigate the effectiveness of PSA, prostate volume (PV) and free-to-total PSA ratio (fPSA%) in predicting patients meeting all active surveillance criteria, including Epstein criteria.

Method: Retrospective analysis was made of the data of 1901 men who underwent transrectal ultrasound (TRUS)-guided prostate biopsy in our clinic between January 2015 and December 2019. The active surveillance criteria were determined as Gleason score ≤6, when specified ≤2 positive cores with <50% cancer involvement in every positive core, a clinical T1c, a PSA <10ng/mL and a PSA density <0.15 ng/mL/cc. Patients who met all active surveillance criteria were included in Group 1, and other patients with prostate cancer were included in Group 2.

Results: The study included 336 patients with available data of age, total-free PSA levels, PV calculated by TRUS. Group 1 consisted of 82 patients and Group 2 consisted of 254 patients. PV and fPSA% were significantly higher and PSA was significantly lower in Group 1 than in Group 2. On multivariate analysis, the independent predictors were determined to be PSA and PV while fPSA% was not.

Conclusion: By using PSA and PV in predicting patients meeting all active surveillance criteria, unnecessary biopsies and ultimately overdiagnosis can be reduced.