Prostate Biopsy in Active Surveillance Protocols: Immediate Re-biopsy and Timing of Subsequent Biopsies

Abstract

There is no consensus regarding the timing of surveillance biopsies; however, an immediate repeat biopsy within 12 months of diagnosis for patients considering AS confirms patients who have favorable risk disease yet also identifies patients who were undersampled initially. Studies regarding multiparametric MRI, nomograms, and biomarkers show promise in risk stratifying and counseling patients during AS. Further studies are needed to determine if these supplemental tests can decrease the frequency of surveillance biopsies. An immediate re-biopsy can help to reduce the risk of missing clinically significant disease. Other clinical tools, including mpMRI, exist that can be used as an adjunct to counsel patients and guide a personalized discussion regarding the frequency of surveillance biopsies.

Upgrading on Per Protocol versus For Cause surveillance prostate biopsies: An opportunity to decreasing the burden of active surveillance

“…While approximately one-fourth of men will be upgraded on their first surveillance biopsy, the other three-fourth will not. 10,11 Furthermore, with the emerging role of AS for select men with low volume GG2 disease, some men will continue on AS despite grade reclassification, further questioning the value of a majority of surveillance biopsies if this invasive procedure will not result in a change in management. Although necessary at times, surveillance biopsies have measurable morbidity with substantial patient discomfort, risk of urinary tract infections, sepsis, and hospitalization, further placing additional financial strain on the healthcare system.…”

“…While approximately one‐fourth of men will be upgraded on their first surveillance biopsy, the other three‐fourth will not 10,11 . Furthermore, with the emerging role of AS for select men with low volume GG2 disease, some men will continue on AS despite grade reclassification, further questioning the value of a majority of surveillance biopsies if this invasive procedure will not result in a change in management.…”

A first step towards a global nomogram to predict disease progression for men on active surveillance

“…A wide variety of predictive factors, including clinical and pathological factors, multi-parametric MRI (mpMRI) data, variability in biopsy timing, and nomograms are currently proposed for men with low-risk PCa on AS (2,3). For example, Wang et al compared the Kattan, Steyerberg, Nakanishi and Chun nomograms to calculate the likelihood of indolent disease as well as various forms of progression in 273 patients meeting low-risk criteria who were managed by AS and who underwent multiple biopsies and/or delayed radical prostatectomy (4).…”