Prostate Biopsy in Active Surveillance Protocols: Immediate Re-biopsy and Timing of Subsequent Biopsies
Purpose of Review
This manuscript reviews contemporary literature regarding prostate cancer active surveillance (AS) protocols as well as other tools that may guide the management of biopsy frequency and assess the possibility of progression in low-risk prostate cancer.
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.
KeywordsProstate cancer Active surveillance Prostate biopsy Repeat biopsy Multiparametric MRI
Compliance with Ethical Standards
Conflict of Interest
Jonathan H. Wang, Tracy M. Downs, E. Jason Abel, Kyle A. Richards, and David F. Jarrard each declare no potential conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 5.Siegel R, Miller K, Jemal A. Cancer statistics, 2015. CA Cancer J Clin. 2015;65:29.Google Scholar
- 7.• Loeb S, Walter D, Curnyn C, Gold HT, Lepor H, Makarov DV. How active is active surveillance? Intensity of followup during active surveillance for prostate cancer in the United States. J Urol. 2016;196:721–6. This SEER database review demonstrates the difficulty of having patients comply with rigerous active surveillance protocol. CrossRefPubMedGoogle Scholar
- 10.Komisarenko M, Timilshina N, Richard PO, Alibhai SMH, Hamilton R, Kulkarni G, Zlotta A, Fleshner N, Finelli A. Stricter active surveillance criteria for prostate cancer do not result in significantly better outcomes: a comparison of contemporary protocols. J Urol. 2016;196:1645–50.CrossRefPubMedGoogle Scholar
- 21.Giulianelli R, Brunori S, Gentile BC, et al. Saturation biopsy technique increase the capacity to diagnose adenocarcinoma of prostate in patients with PSA< 10 ng/ml, after a first negative biopsy. Arch Ital di Urol Androl organo Uff [di] Soc Ital di Ecogr Urol e Nefrol. 2011;83:154–9.Google Scholar
- 24.• King AC, Livermore A, Laurila TAJ, Huang W, Jarrard DF. Impact of immediate TRUS rebiopsy in a patient cohort considering active surveillance for favorable risk prostate cancer. Urol Oncol Semin Orig Investig. 2013;31:739–43. This paper supports the use of an immediate, confirmatory biopsy in patients considering active surveillance, to reduce the risk of undersampling. CrossRefGoogle Scholar
- 30.Thompson JE, Hayen A, Landau A, Haynes A-M, Kalapara A, Ischia J, Matthews J, Frydenberg M, Stricker PD. Medium-term oncological outcomes for extended vs saturation biopsy and transrectal vs transperineal biopsy in active surveillance for prostate cancer. BJU Int. 2015;115:884–91.CrossRefPubMedGoogle Scholar
- 32.Alberts AR, Roobol MJ, Drost F-JH, van Leenders GJ, Bokhorst LP, Bangma CH, Schoots IG. Risk-stratification based on magnetic resonance imaging and prostate-specific antigen density may reduce unnecessary follow-up biopsy procedures in men on active surveillance for low-risk prostate cancer. BJU Int. 2017; doi: 10.1111/bju.13836.Google Scholar
- 34.Adamy A, Yee DS, Matsushita K, Maschino A, Cronin A, Vickers A, Guillonneau B, Scardino PT, Eastham JA. Role of prostate specific antigen and immediate confirmatory biopsy in predicting progression during active surveillance for low risk prostate cancer. J Urol. 2011;185:477–82.CrossRefPubMedGoogle Scholar
- 42.• Blute ML, Shiau JM, Truong M, Shi F, Abel EJ, Downs TM, Jarrard DF. A biopsy-integrated algorithm for determining Gleason 6 upgrading risk stratifies risk of active surveillance failure in prostate cancer. World J Urol. 2016; doi: 10.1007/s00345-016-1933-0. This article applies a biopsy-driven nomogram in predicting upgrading risk during active surveillance. PubMedGoogle Scholar
- 43.•• Iremashvili V, Manoharan M, Kava BR, Parekh DJ, Punnen S. Predictive models and risk of biopsy progression in active surveillance patients. Urol Oncol Semin Orig Investig. 2017;35:37.e1–8. This review compares various normograms and their ability to predict progression of cancer during active surveillance. CrossRefGoogle Scholar
- 54.Fütterer JJ, Briganti A, De Visschere P, Emberton M, Giannarini G, Kirkham A, Taneja SS, Thoeny H, Villeirs G, Villers A. Can clinically significant prostate cancer be detected with multiparametric magnetic resonance imaging? A systematic review of the literature. Eur Urol. 2015;68:1045–53.CrossRefPubMedGoogle Scholar
- 57.•• Wysock JS, Rosenkrantz AB, Huang WC, Stifelman MD, Lepor H, Deng F-M, Melamed J, Taneja SS. A prospective, blinded comparison of magnetic resonance (MR) imaging–ultrasound fusion and visual estimation in the performance of MR-targeted prostate biopsy: the PROFUS trial. Eur Urol. 2014;66:343–51. This prospective, blinded study confirms that ultrasound fusion biopsies are better able to detect cancer than visual, cognitive biopsies. CrossRefPubMedGoogle Scholar
- 58.Da Rosa MR, Milot L, Sugar L, Vesprini D, Chung H, Loblaw A, Pond GR, Klotz L, Haider MA. A prospective comparison of MRI-US fused targeted biopsy versus systematic ultrasound-guided biopsy for detecting clinically significant prostate cancer in patients on active surveillance. J Magn Reson Imaging. 2015;41:220–5.CrossRefPubMedGoogle Scholar
- 61.Vargas HA, Hötker AM, Goldman DA, et al. Updated prostate imaging reporting and data system (PIRADS v2) recommendations for the detection of clinically significant prostate cancer using multiparametric MRI: critical evaluation using whole-mount pathology as standard of reference. Eur Radiol. 2016;26:1606–12.CrossRefPubMedGoogle Scholar
- 68.•• Droz J-P, Albrand G, Gillessen S, et al. Management of prostate cancer in elderly patients: recommendations of a task force of the International Society of Geriatric Oncology. Eur Urol. 2017; doi: 10.1016/j.eururo.2016.12.025. This article represents the latest guidelines on approaching prostate cancer treatment in the geriatric population. Google Scholar