The mainstay of diagnosis in the USA and Europe for the past 20 years has been trans-rectal prostate biopsy carried out under local anaesthetic using a rectal ultrasound probe to guide the biopsies into 12 distinct areas of the peripheral zone of the prostate (Fig. 7.1). The ability of the ultrasound to detect abnormal lesions within the prostate is dependent on both the technology being available to deliver a sharp image and also the operator having the experience to recognise and target the abnormality (Toi et al. 2007).

The European Association of Urology (EAU) guidelines for trans-rectal biopsy are:

There are currently two indications for a prostate biopsy: an abnormal DRE and a raised PSA. Since the use of PSA testing began in the 1980s there has been a gradual lowering of the threshold of PSA that triggers a biopsy. In the ERSPC, the threshold was 3 ng/ml, but age related ranges and higher values are also in widespread usage. The risk of prostate cancer diagnosis rises with the PSA level, but the Prostate Cancer Prevention Trial (PCPT) demonstrated that there is no safe lower level of PSA at which the risk of high grade disease is zero (Thompson et al. 2004). It is considered good practice to repeat any mildly raised PSA before proceeding to a biopsy.

There has been interest in reducing the number of unnecessary biopsies undertaken without lowering the detection of high grade tumours. Biomarkers have been used to improve the diagnostic accuracy of PSA. They include: the ratio of prostate cancer gene 3 (PCA3) ribonucleic acid (RNA) to PSA RNA, serum PSA parameters (PSA velocity, PSA doubling time, percentage free PSA, PSA density, and age-specific PSA), and panels of serum kallikreins (total PSA, free PSA and kallikrein-related peptidase 2). These have been used, or are currently being evaluated, to try to reduce the number of unnecessary biopsies (Bryant et al. 2014). The Beckman Coulter Prostate Health Index (PHI) uses a mathematical formula combining total PSA, percentage free PSA and pro-PSA and seems to be a significant predictor of prostate cancer at initial prostate biopsy in men whose PSA is between 2 ng/ml and 10 ng/ml (Guazzoni et al. 2011).

The decision to recommend a prostate biopsy is an individual one and will depend on some of the factors mentioned above, and also the family history and general health of the patient. It should be noted, however, that there is currently an on-going recent move away from trans-rectal biopsies due to increasing problems with antibiotic resistance making infection post-biopsy more likely. The concern over the both the over-diagnosis of biologically insignificant tumours and post-biopsy sepsis has led to an increased use of pre-biopsy imaging with MRI scanning.

A DRE has a poor sensitivity and specificity, but if abnormal, is an indication to perform a prostate biopsy irrespective of the PSA result – as an abnormal DRE is usually indicative of a cancer with a higher Gleason score (Okotie et al. 2007). Although the data is poor from SSA, the studies that have been undertaken have shown a high percentage of abnormal DRE and high clinical stage (stage > T2) from 20.2% in Yamoah et al.’s (2013) study in Ghana to 81.4% in Ekwere et al.’s (2002) Nigerian patients. This is as one would expect due to the low use of PSA testing and influences the likely treatment options available to the majority of these patients.

Multi-parametric magnetic resonance imaging (mpMRI) can potentially visualise prostate cancer tumours larger than 0.5 cm³ with 93% sensitivity and 98% negative predictive value (Pokorny et al. 2014), but there is controversy surrounding its use as a sole diagnostic tool as recent reports suggest it may miss up to 26% of significant tumours found in removed prostates (Le et al. 2014). The reporting of mpMRI will improve and although not currently the standard of care this situation is likely to change due to the impetus to reduce the unnecessary number of biopsies being performed and to reduce the post biopsy sepsis rate. The mpMRI approach allows a targeted biopsy performed under a general anaesthetic significantly reducing the sepsis rate from 2 to 3% for the transrectal approach to a more acceptable 0.1%. It is also becoming the recommended approach to monitor those patients on active surveillance for low-risk prostate cancer (Fig. 7.3).

A recent study audited the prostate cancer biopsy practice in centres of six SSA countries (Senegal, Ghana, Sudan, Uganda, South Africa and Botswana) (Jalloh et al. 2013). In total, only 4672 black men underwent prostate biopsy between the years of 2005 and 2011. Of these 1241 (27%) had a positive biopsy with the highest Gleason grades (Schroder et al. 2014; Hugosson et al. 2015; Andriole et al. 2012) in Sudan and Uganda. There was criticism of the biopsy techniques used in these centres and none complied with the current EAU guidelines as mentioned above. One of the major problems encountered in these countries is the lack of pathologists. A survey report by showed that in 2012 the highest number of pathologists per person was 1:226,470 in Botswana and 1:297,000 in SA followed by 1:500,000–1,000,000 in Ghana Kenya and Nigeria with all the other SSA countries having a greater ratio than 1:1,000,000. In comparison the ratios in the UK is 1:15,000 with a large proportion having a sub-speciality interest.

The treatment of prostate cancer is dependent upon the stage and grade of the cancer at presentation, and the general fitness of the patient. There has been a trend over the last 10 years to offer active surveillance for patients with low risk disease. There are many risk categories based on the PSA, cancer grade and the number of cores affected, as well as the clinical stage on DRE.

The most commonly used is the D’Amico category (D’Amico et al. 2005):

Low Risk:

Intermediate Risk:

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