A 64-year-old-man underwent PSA testing during his annual physical with his primary care physician; PSA was 5.6 ng/mL and PSA density was 0.16.
He then saw a urologist, who ordered a multiparametric MRI; result was PI-RADS 4.
The patient was reluctant to undergo a prostate fusion biopsy, therefore the patient’s urologist recommended that he undergo exosome-based molecular testing to help determine risk of prostate cancer; his test score was 16.3.
The patient and urologist remained concerned about his PI-RADS 4 MRI score. The urologist also noted that the PSA density of 0.16 was slightly above the threshold of 0.1.
The patient elected to undergo TRUS-guided biopsy, which was negative for prostate cancer.

Judd W. Moul, MD, FACS: We have seen a lot of flux in the incidence and diagnosis of the prostate cancer, especially over the last decade. As a lot of us know, the United States Preventive Services Task Force in 2012 recommended against the PSA [prostate-specific antigen] test. So for a period between 2012 and 2018, we had a situation where primary care physicians were not doing the PSA test, not screening for prostate cancer. The incidence of prostate cancer actually went down, even though the underlying rate of prostate cancer in the population didn’t go down with our aging population. As a result, now what we are seeing is a higher rate of advanced prostate cancer, and most recently we have statistics sadly showing that the death rates from prostate cancer are going up because of this 6- to 8-year period where our primary care colleagues for the most part did not recommend the PSA test. But because of the aging population and because of these new data showing higher mortality from prostate cancer, primary care physicians over the last year or two have been rediscovering the PSA test and rediscovering prostate screening. I think most urology practices are starting to again see an uptick in referrals for an elevated PSA, and as a result the incidence of prostate cancer is going up again.

The question as far as what percentage of patients have indolent prostate cancer versus clinically important prostate cancer or more aggressive prostate cancer somewhat depends on the patient population that the urologist is seeing. For example, if a urologist has a larger population of African American men, they are going to see a higher proportion of Gleason 7 [score] or higher prostate cancer. In my practice in Durham, North Carolina, it’s 50-50, so 40% to 50% of the patients will have that lower Gleason score and potentially be candidates for a monitoring program or active surveillance, and half the patients will have a more aggressive prostate cancer, such as Gleason 7. It somewhat depends on the patient population.

Transcript edited for clarity.