Biopsy recommended, is this correct next step?

The usual steps are, yearly DRE & PSA. If anything suspicious with those tests then MRI, if anything significant on MRI then a Biopsy. If Gleason more then a 6 on biopsy then a PSMA PET/CT scan. Looking at your stats I would not think a biopsy would be necessary and more a candidate for AS (active surveillance). But I'm not a doctor and maybe there is more to your history why the doctor wants to do a biopsy. If you do have a biopsy make sure it's a Transperineal not Transrectal. I would usually suggest asking for a "fusion guided" biopsy but your MRI didn't show anything to "fuse / map" to. You posted you are seeing a very good doctor my first question would be "with my test results why would you suggest a biopsy and not AS". Wishing you the best

I'm not a medical professional so take my comments with a grain of salt. I agree with @copyman that the transperineal is the one I'd prefer due to a much reduced chance of infection. The only way I'd do the transrectal was if the doctor said there was some reason why the transrectal was needed in my case. While I see nothing wrong with asking the doctor why he wants a biopsy, My understanding is that MRI's fail to image about 10% to 15% of intermediate (or worst) prostate cancers. Since it's so much better to catch prostate cancer early rather than late, I suspect your doctor is just trying to be prudent, especially since for most guys a biopsy isn't that big of a deal. I had one at age 70, and the very next day started a 10 day road trip with only very minor inconvenience. BTW, at the time I was convinced that I didn't have prostate cancer, but the biopsy came back 3+4=7. I ended up having surgery, and the resulting pathology then also found cribriform and IDC. One other option might be to ask your doctor if the PSE test is a reasonable test before deciding if the biopsy is needed. Even if you had a biopsy, a PSE might still be a reasonable test to do if the biopsy failed to find anything. Again, I'm not a medical professional and this is just my 2 cent opinion. Best wishes.

I just had a robotic prostatectomy in Feb 2025 as my Gleeson levels were 9 ( bad )
.. my pet scan told the dr it
was contained Ie : still in the prostate .. said get that bastard out .. which he did 🤣
Mike 🦘🇦🇺

Has your PSA been on a steady increase from 4 to 7.3 or did it take a large jump? If you have significant cancer your PSA will continue to increase. Start with antibiotics and a repeat PSA to eliminate infection creating a temporary PSA increase. The PSE is a blood test more accurate than ExoDx so that can also be done before a biopsy. If those indicate cancer get a second mpMRI (should be able to after a year) to see if anything can be found to target with a fusion biopsy. It is not unusual for random biopsies to miss cancer since less than 1% of prostate is sampled.

I disagree about biopsies not being a big deal. I feel biopsies are barbaric, especially when so many are done unnecessarily. Plus if done transrectal there is always a chance of infection. And if a blind biopsy it can be even more useless. Personally I would not have a biopsy done unless something showed on MRI. As mentioned there are other blood tests to detect prostate cancer and would do these before a blind biopsy.

@copyman
I had three transrectal biopsies 16 years ago. They were a little uncomfortable, but not a big deal. They didn’t do MRIs back then. They did do a CT scan before the third one and then did it to make sure I didn’t have Seminal vesicle invasion.

I definitely wouldn’t call it barbaric. Much better today that they have guided biopsies after an MRI.

My transrectal was no big, alot more effort put into getting a colonoscopy. Always chance of infection or error there too. My urologist said he had never had a patient incur an infection, and patients from the other Urologist that had learned that their patients did not follow the antibiotic courses exactly. I had two different antibiotic’s. The blood tests to detect the cancer just ultimately guide you to a biopsy or MRI then a fusion guided biopsy if lesions are found. You could have the blood tests indicate high likelihood of cancer, but no idea what Gleason, aggressiveness, or where for possible focal treatment. A positive blood test but no PIRADS lesions on the MRI would lead to a random grid biopsy. Interesting in my case, my PIRADS 4 lesion and the reason for the biopsy turned out to be benign, but the random grid turned up two Gleason 6, two Gleason 7 and one Gleason 8. If a random grid is done sufficiently in a proper manner it will usually catch. It is like anything though, whether a CT , PET , or MRI statistically things do get missed.

Off topic, but I do not understand why many urologists are no longer doing DREs. Sure, if the patient absolutely is against it, but otherwise why not get one more bit of information?

Wow, I am impressed that I received so many high-quality responses, and so thoughtful, especially on a holiday.
Thank you all so much!!
To address the several points:
The biopsy was offered as an option vs active surveillance, they were not pushing it. I zoned into the biopsy option because I am scared of cancer, I’ve seen a lot of it in my family. Biopsy seems a limited risk way to determine what is really going on given the PSA results (high but quite variable with no satisfactory explanation). Then I started second guessing myself. After reading these responses, I am feeling more assured on pursuing the biopsy, understanding the point that transperineal is better/lower risk.
I was unaware of the PSE test, I have researched that and will bring that into the conversation with the urologist (DRE’s seem to be out of fashion, both my urologist and my GP state that they prefer other methods of risk identification and stratification, MRI, ExoDx, etc.)
Jim18 asked the rate of change, here’s my PSA history
4/7/26 = 7.4 retested with no sex 5+ days
3/27/2026 = 8.3 (sex day before);
11/19/2025 = 6.4
5/5/2025 = 7.1
3/12/2025 = 5.8 (Free PSA 1.12, % free PSA 19.3)
4/24/2024 = 3.4. Urinalysis also clear; ExoDx test “4.34 score, well below the 15.6 cutoff”
2/2024 = 4.3 (Free PSA .74. % free PSA 17.2);
6/2023 = 3.18
3/2022 = 2.1
2/2022 = 7.2 pushed it down with Doxycycline and Avodart/Dutasteride
12/2020=3.4
10/2019=2.3
1/2018 = 3.5
3/2017 = 1.8
12/2015=7.0 (then retested and went down, I do not have those results)
12/2014=1.3
Thank you all for your thoughtful comments!!!

@stevemcdonald Your high PSAs in 2015 and 2022 were caused by some type of infection/inflammation. PSA does not go down that much if it was being produced by cancer. The free PSA is in the gray zone (>10 & < 25). Your ExoDx was taken with a PSA of 3.4 two years ago so that does not mean you do not have cancer today. It would be better if a target could be identified vs totally random biopsy so another mpMRI would be useful. The random part of my biopsy identified a single 3+3 core at 5% involved, good for active surveillance. However, the targeted lesion had all 3 cores at 4+4 with 30% involved creating a very different treatment plan. This was with a PSA of 7.7, 18% free. I had transrectal with local and had no issues during or after procedure. Drove home a few minutes after the biopsy.