Introduction Prostate cancer is the commonest male malignancy diagnosed in countries in the Western World and it represents the second commonest cause of male cancer-related death. In the United Kingdom in 2008 37,051 new cases of prostate cancer were diagnosed and this malignancy resulted in 10,168 deaths. The morbidity and mortality directly attributable to this common malignancy is considerable, however in some patients the disease is often relatively indolent. Prostate cancer is typically a

more »

... disease associated with the aging male population however in some cases it may be lethal in a younger subset of men. The degree of benefit to be gained from diagnosing and treating prostate cancer is directly related to the degree of comorbidity and life expectancy of individual men. It is crucial to identify as accurately as possible men at increased risk of prostate cancer in order to improve the diagnostic performance of a prostate biopsy. Moreover it is important to be able to restrict this invasive investigation to men who are likely to benefit from treatment of this malignancy. There are currently concerns that Western clinicians and healthcare providers are over-diagnosing large numbers of men who would otherwise never have been troubled by their clinically undetectable prostate cancer. Moreover there are also concerns that large numbers of men are currently being over-treated for their prostate malignancy, resulting in treatment-related morbidity including surgical and radiotherapy complications such as erectile dysfunction and urinary incontinence. Over the last 25 years urologists and researchers have refined their skills sufficiently well to enable accurate diagnosis of a considerable proportion of prostate cancers. The contemporary challenge however is to diagnose with increased confidence those "clinically significant" cases of prostate cancer which by definition are likely to pose a threat to an individual patient if left undetected. The first part of this chapter outlines the current predictors of prostate cancer on biopsy including clinical, laboratory and research tools. Factors which may help the prediction of prostate cancer on repeat biopsy, as well as current diagnostic performance of prediction tools utilising pre-and post-biopsy data to identify men at high risk of harbouring clinically significant and aggressive prostate cancer are discussed.