Letter to the Editor NOT referring to a recent journal article

Does Low-Risk Prostate Cancer Detection Change With Repeat Biopsies?

By: Bobby B. Najaria , Michael Rinka b , Markus Graefenc, Shahrokh F. Shariata d lowast and Felix K. Chunb

European Urology, Volume 61 Issue 1, January 2012, Pages 230-231

Published online: 01 January 2012

Abstract Full Text Full Text PDF (62 KB)

Many patients with a negative prostate biopsy (PBx) but persistent clinical suspicion of prostate cancer (PCa) undergo repeat PBx. On repeat PBx, there are higher rates of low-grade and organ-confined PCa, which are associated with lower risk of disease progression and cancer-specific mortality [1] and [2]. Increasing emphasis is being placed on treating only clinically significant disease [1]. We hypothesize that a considerable risk of clinically significant PCa remains on repeat PBx. Therefore, we reviewed a contemporary cohort of patients who underwent one or more PBx.

We retrospectively reviewed the data from a cohort of 25 584 patients who underwent PBx at two institutions. One dedicated uropathologist evaluated 90% of PBx specimens; the remaining specimens were evaluated by two other uropathologists. To ensure current pathologic grading standards, the study was limited to patients biopsied from 2004 to 2010. Only patients with at least 10 cores taken were included. Statistical analysis was performed using SPSS v.17.0 (SPSS Inc., IBM Corp., Armonk, NY, USA). Descriptive statistics are reported as medians with interquartile ranges (IQRs). All tests were two-sided, and a p value of 0.05 was considered statistically significant.

Of 25 584 patients, 6729 met the inclusion criteria, and 764 (11.3%) of those underwent a second PBx after negative initial biopsy. The median age was 65 yr (IQR: 9.0), prostate-specific antigen (PSA) was 6.20 ng/ml (IQR: 4.79), and prostate volume was 47ml (IQR: 30). Overall, 3671 (54.6%) men were diagnosed with PCa on first PBx, whereas 199 (26.0%) had a positive second PBx (p<0.01). Although age and PSA were not significantly different between these two groups, men with prostate glands <50ml were more likely to be diagnosed with PCa on initial biopsy versus second biopsy (63.3% vs 50.3%, p<0.01; Table 1). Cancers detected on the second PBx were more likely to be Gleason 6 than cancers detected on initial PBx (60.8% vs 46.1%, p<0.01). We further categorized men as having low-risk PCa, as defined by PSA <10 ng/ml, Gleason 6, clinical stage T2a or lower, and two or fewer positive biopsy cores. The proportion of low-risk patients was significantly higher in repeat PBx compared to initial PBx (36.2% vs 23.6%, p<0.01). Patients with low-risk PCa were younger (65 yr [IQR: 8] vs 66 yr [IQR: 9], p<0.01), had lower PSA (5.31 ng/ml [IQR: 2.7] vs 7.37ng/ml [IQR: 6.31], p<0.01), and had larger prostate volume (47ml [IQR: 26] vs 42ml [IQR: 25], p<0.01).

Table 1 Outcomes on positive first and second biopsies

Parameter Positive initial biopsy Positive second biopsy p
n=3669 n=199
Age, median (IQR) 65.0 (9.0) 66.0 (9.25) >0.05a
PSA, median (IQR) 6.54 (3.00) 7.26 (5.02) >0.05a
Volume, median (IQR) 43.0 (26.0) 47.5 (30.0) <0.01a
TRUS volume, n (%) <0.01b
<30 607 (17.1) 21 (11.5)
30–49 1635 (46.2) 71 (38.8)
50–70 776 (21.9) 50 (27.3)
≥70 523 (14.8) 41 (22.4)
Gleason grade, n (%) <0.01b
6 1693 (46.1) 121 (60.8)
7 1479 (40.3) 60 (30.2)
≥8 497 (13.5) 18 (9.0)
Low risk, n (%) 865 (23.6) 72 (36.2) <0.01b

a Wilcoxon rank-sum test.

b Chi-square test.

IQR=interquartile range; PSA=prostate-specific antigen; TRUS=transrectal ultrasound.

Despite having a negative initial PBx, more than a quarter of men who underwent a repeat biopsy in our large cohort had PCa detected. As expected, men with larger prostates were less likely to be diagnosed on initial biopsy [3]. Despite the pathologic characteristics being more favorable on repeat PBx, almost two-thirds of these men still had intermediate- or high-risk PCa. Conclusions from our study are limited by its retrospective design and its lack of long-term clinical and survival outcomes to further examine the significance of our findings.

In conclusion, men for whom there is persistent suspicion of PCa despite a negative PBx should be counseled that repeat biopsies detect high numbers of clinically significant PCa.

Conflicts of interest

The authors have nothing to disclose.


  • [1] F.K.H. Chun, J.I. Epstein, V. Ficarra, et al. Optimizing performance and interpretation of prostate biopsy: a critical analysis of the literature. Eur Urol. 2010;58:851-864 Abstract, Full-text, PDF, Crossref.
  • [2] F.H. Schröder, R.C.N. van den Bergh, T. Wolters, et al. Eleven-year outcome of patients with prostate cancers diagnosed during screening after initial negative sextant biopsies. Eur Urol. 2010;57:256-266
  • [3] J.L. Letran, G.E. Meyer, F.R. Loberiza, M.K. Brawer. The effect of prostate volume on the yield of needle biopsy. J Urol. 1998;160:1718-1721


a Department of Urology, Weill Cornell Medical Center of Cornell University, New York, NY, USA

b Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

c Martini Clinic - Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

d Division of Medical Oncology, Weill Cornell Medical Center of Cornell University, New York, NY, USA

lowast Corresponding author. Weill Cornell Medical College, Brady Urologic Health Center, 525 East 68th Street, Box 94, Starr 900, New York, NY 10065, USA.

Both authors contributed equally to the manuscript.

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