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Article of the Week: Complications after serial prostate biopsies in men on AS

Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

 

Complications after prostate biopsies in men on active surveillance and its effects on receiving further biopsies in the Prostate cancer Research International: Active Surveillance (PRIAS) study

Leonard P. Bokhorst*, Inari Lepisto†, Yoshiyuki Kakehi‡, Chris H. Bangma*, Tom Pickles§, Riccardo Valdagni¶, Arnout R. Alberts*, Axel Semjonow**, Petra Str
olin††, Manuel F. Montesino‡‡, Viktor Berge§§, Monique J. Roobol* and Antti Rannikko†

*Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands,
†Department of Urology, Helsinki University Central Hospital, Helsinki, Finland,
‡ Department of Urology, Kagawa University Faculty of Medicine, Kagawa, Japan,
§Department of Radiation Oncology, British Columbia Cancer Agency, Vancouver, BC, Canada,
¶Prostate Cancer Program and Radiation Oncology 1, Fondazione IRCSS Istituto Nazionale dei Tumori, Milan, Italy,
**Department of Urology, Prostate Center, University Hospital Muenster, Muenster,
††Department of Urology, Martini Klinik, Hamburg, Germany,
‡‡Department of Urology, Hospital Virgen del Camino, Pamplona, Spain, and
§§Department of Urology, Oslo University Hospital, Oslo, Norway

 

 

Objective

To study the risk of serial prostate biopsies on complications in men on active surveillance (AS) and determine the effect of complications on receiving further biopsies.

Patients and methods

In the global Prostate cancer Research International: Active Surveillance (PRIAS) study, men are prospectively followed on AS and repeat prostate biopsies are scheduled at 1, 4, and 7 years after the diagnostic biopsy, or once yearly if prostate-specific antigen-doubling time is <10 years. Data on complications after biopsy, including infection, haematuria, haematospermia, and pain, were retrospectively collected for all biopsies taken during follow-up in men from several large participating centres. Generalised estimating equations were used to test predictors of infection after biopsy. Competing risk analysis was used to compare the rates of men receiving further biopsies between men with and without previous complications.

Results

In all, 2 184 biopsies were taken in 1 164 men. Infection was reported after 55 biopsies (2.5%), and one in five men reported any form of complication. At multivariable analysis, the number of previous biopsies was not a significant predictor of infection (odds ratio 1.04, 95% confidence interval 0.76–1.43). The only significant predictor for infection was the type of prophylaxis used. Of all men with a complication at the diagnostic or first repeat biopsy, 21% did not have a repeat biopsy at the time a repeat biopsy was scheduled according to protocol, vs 12% for men without a previous biopsy complication.

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Conclusion

In our present cohort of men on AS, we found no evidence that repeat prostate biopsy in itself posed a risk of infection. However, complications after biopsy were not uncommon and after a complication men were less likely to have further biopsies. We should aim to safely reduce the amount of repeat biopsies in men on AS.

 

Editorial: Active surveillance for prostate cancer: is it too active?

The wide dissemination of prostate cancer screening has increased the number of men diagnosed with low-risk, indolent cancers that are better managed with active surveillance (AS) rather than immediate treatment. During the past decade, the number of men managed with AS has increased from <10% to 40% in community based practice registries [1]. Prostate needle biopsy has a central role in diagnosis and reclassification of cancer for men on AS, and the number of these procedures has increased on an individual patient level and overall in the population. The rise of prostate biopsies repeated in the same patients has mirrored the increased rate of biopsy related infectious complications. An association between the number of repeat prostate biopsies and risk of infectious complications was reported in a single-centre observational study [2].

In this issue of BJUI, Bokhort et al. [3] report the risk of complications of serial prostate biopsies in men on AS in the multi-institutional Prostate cancer Research International Active Surveillance (PRIAS) study. Although they did not identify the number of previous biopsies as an independent predictor of infection, the type of prophylactic antibiotic was associated with risk of infection. Overall, one in five men reported any complication during AS and the rate of infectious complications was 2.5%. These figures are more relevant if we consider that men in whom an infection occurred were twice as likely to discontinue AS. Although the rate of attrition may have confounded the association of repeat biopsies on infectious complications or guided a more augmented antibiotic prophylaxis regimen, the most important finding of this study remains the significant morbidity associated with AS.

In the PRIAS study, institutions are guided to perform surveillance biopsies at 1, 4, and 7 years after the diagnostic biopsy. However, the schedule of biopsies varies significantly globally across institutions. In some academic centres, prostate biopsies are taken annually for men on AS, while other experts in AS have discussed taking biopsies every 5 years [4, 5]. As more studies emerge demonstrating the oncological safety of AS, we must address how ‘active’ AS should be and develop individualised recommendations based on tumour characteristics. A barrier to AS remains the burden of morbidity associated with prostate biopsies and efforts to reduce these procedures will contribute to further reducing the overtreatment of men with low-risk prostate cancer. In addition, the patient costs associated with serial office visits and the burden on physicians and healthcare systems stemming from the increased clinical volume following these patients remain an unmet need for the future.

 

Behfar Ehdaie
Department of Surgery, Urology Service, and Department of Epidemiology and Biostatistics, Center of Health Policy and Outcomes, Memorial Sloan Kettering Cancer Center, New York, NY, USA

 

References

1. Cooperberg MR, Carroll PR. Trends in management for patients with localized prostate cancer, 1990–2013. JAMA 2015; 314: 802

 

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