
Elevated PSA in Primary Care: What to Consider Before Biopsy
Mina Fam, MD, reviews risk-based PSA interpretation, prostate MRI, biomarkers, and targeted biopsy in the modern diagnostic pathway.
An elevated prostate-specific antigen (PSA) level should begin a risk assessment, not automatically send a patient to biopsy, Mina Fam, MD, a urologic oncologist at Hackensack Meridian Health in New Jersey, explains. Fam recommends earlier conversations for men at increased risk of developing
That framework is consistent with the 2023 American Urological Association and Society of Urologic Oncology guideline. It recommends shared decision-making and allows clinicians to offer baseline PSA testing between ages 45 and 50 for average-risk patients. For persons at increased risk of developing prostate cancer, including Black men and those with germline mutations or a strong family history, the guideline advises beginning screening discussions at age 40 to 45.¹ It also recommends repeating a newly elevated PSA before proceeding to a secondary biomarker, imaging, or biopsy because some values normalize on retesting.
Fam then describes how multiparametric MRI, targeted biopsy, and blood- or urine-based biomarkers have made the diagnostic pathway more selective. In the PRECISION randomized trial, an MRI-first pathway in biopsy-naive men avoided biopsy in 28% of participants and detected more clinically significant cancers than standard systematic biopsy.² MRI is not perfect, however, and decisions about targeted, systematic, or combined sampling should reflect the patient’s overall risk and local expertise.
Biopsy technique is changing as well. In the randomized PREVENT trial, office-based transperineal biopsy without antibiotic prophylaxis produced no infections in the transperineal group versus infections in 1.4% of men undergoing transrectal biopsy with targeted prophylaxis; clinically significant cancer detection was similar.³
For primary care, the message is to confirm the result, review reversible contributors and prior trends, and refer with relevant risk information. MRI and biomarkers refine probability; they do not independently rule cancer in or out. A structured pathway can reduce avoidable biopsy while preserving detection of disease likely to matter.
Fam has no relevant disclosures.
References
1. Wei JT, Barocas D, Carlsson S, et al. Early Detection of Prostate Cancer: AUA/SUO Guideline Part I: Prostate Cancer Screening. J Urol. 2023;210:46-53.
2. Kasivisvanathan V, Rannikko AS, Borghi M, et al. MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis. N Engl J Med. 2018;378:1767-1777.
3. Hu JC, Assel M, Allaf ME, et al. Transperineal Versus Transrectal MRI-targeted and Systematic Prostate Biopsy to Prevent Infectious Complications: The PREVENT Randomized Trial. Eur Urol. 2024;86:61-68.


























































































































