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European UrologyVolume 61, issue 6, pages e53-e66, June 2012
Reply from Authors re: Alexandre R. Zlotta, Robert K. Nam. To Biopsy or Not to Biopsy—Thou Shall Think Twice. Eur Urol 2012;61:1115–7: Considerations for Prostate Biopsy Decisions
Published online 8 March 2012, pages 1117 - 1118
Refers to article:
To Biopsy or Not to BiopsyThou Shall Think Twice
June 2012 (Vol. 61, Issue 6, pages 1115 - 1117)
Refers to article:
Infectious Complications and Hospital Admissions After Prostate Biopsy in a European Randomized Trial
Accepted 28 December 2011
June 2012 (Vol. 61, Issue 6, pages 1110 - 1114)
Our group recently reported an increasing frequency of hospitalizations after prostate biopsy  consistent with numerous international studies  and . This subject has important public health implications because prostate biopsies continue to be performed commonly. In 2008, approximately 370 733 new prostate cancer (PCa) cases were diagnosed in Europe . Estimating a PCa detection rate of approximately 30% on biopsy, this would suggest that >1 million prostate biopsies were performed in Europe that year. Among US Surveillance Epidemiology and End Results–Medicare participants from 1993 to 2001, Welch and colleagues showed that 10%, 14%, and 18% of men undergoing first, second, and third biopsy, respectively, had a repeat biopsy within 1 yr .
Because prostate biopsy is necessary as part of the diagnostic workup for abnormal screening tests, the frequency of unnecessary biopsies and complications from biopsy are germane to the screening debate. As discussed by Zlotta and Nam , PCa overdiagnosis is also a potential downstream consequence of PCa screening. However, it is noteworthy that several strategies to reduce overtreatment, such as active surveillance or focal therapy, also involve repeated and/or more extensive biopsy sampling . Unfortunately, prostate-specific antigen (PSA) kinetics and other serum markers have not been shown to offer sufficient discrimination of progressive disease to replace the need for serial biopsy sampling during active surveillance  and . We are planning additional follow-up analyses to compare the risks for men undergoing repeat biopsies compared to initial biopsies. Regardless, it is clear that ensuring the safety of prostate biopsy is an important issue across the spectrum of PCa care.
Prostate biopsy is so critical in all of these settings because of the substantial drawbacks of contemporary noninvasive staging modalities. In the future, the discovery of better biomarkers or improvements in technology such as magnetic resonance imaging  may help to reduce or possibly replace the need for biopsy in some cases.
In the meantime, this situation can be improved through greater selectivity in choosing candidates for screening and biopsy. One way to do this is to avoid screening for men with significant comorbidity, with a greater risk of biopsy complications, and with less to gain from early PCa diagnosis . Another way to do this is through the use of more specific markers for PCa and clinically significant disease. For example, PSA velocity risk count (counting the number of times that PSA velocity exceeds 0.4 ng/ml per year in a row) was recently shown to significantly improve the discrimination of high-grade PCa on biopsy compared to PSA alone .
There is an increasing shift away from “one size fits all” toward a risk-adapted screening approach . For example, the European Randomized Study of Screening for Prostate Cancer risk calculator represents a method of risk-adapted screening that calculates PCa probabilities based on PSA levels together with findings from digital rectal examination (DRE) and transrectal ultrasound (TRUS; eg, hypoechoic lesions, prostate volume) . This tool has now been externally validated  and appears to be well accepted in the clinical setting. In a multi-institutional study within the Netherlands, van Vugt et al. reported compliance with the risk calculator recommendation for or against biopsy in 83% of cases .
Recently, our group showed that prostate size estimates from DRE could be used in the model with only a slight impact on performance characteristics . Certainly DRE is less invasive than a TRUS examination and could expand the utilization of this type of risk-adapted approach. Nevertheless, if the risks of prostate biopsy continue to increase, a potential role for TRUS in reducing the need for proceeding to invasive biopsy may become more acceptable.
The critical question for any intervention is whether the benefits outweigh the associated harms, which would include prostate biopsy complications. In our study, 118 men would need to be biopsied to lead to a hospitalization . In contrast, in the Gothenburg randomized population-based trial, only 12 men needed to be diagnosed to save a life from PCa at 14 yr  and even fewer needed to be diagnosed to prevent one case of metastatic disease. Although there are many other potential consequences of screening, the benefits with reduced metastases and PCa deaths would appear to outweigh the specific potential harm of hospitalization from prostate biopsy. We concluded that the low absolute frequency of serious infectious complications after prostate biopsy should not itself serve as a deterrent for men who would otherwise benefit from early PCa diagnosis.
Conflicts of interest
The authors have nothing to disclose.
Stacy Loeb was supported by the Society of Women in Urology Elisabeth Pickett Research Award. The ERSPC Rotterdam is supported by the Dutch Cancer Society (KWF 94-869, 98-1657, 2002-277, 2006-3518, 2010-4800) and the Netherlands Organization for Health Research and Development (ZonMW-002822820, 22000106, 50-50110-98-311, 62300035).
-  S. Loeb, S. van den Heuvel, X. Zhu, et al. Infectious complications and hospital admissions after prostate biopsy in a European randomized trial. Eur Urol. 2012;61:1110-1114 Abstract, Full-text, PDF, Crossref.
-  R.K. Nam, R. Saskin, Y. Lee, et al. Increasing hospital admission rates for urological complications after transrectal ultrasound guided prostate biopsy. J Urol. 2010;183:963-968
-  S. Loeb, H.B. Carter, S.I. Berndt, W. Ricker, E.M. Schaeffer. Complications after prostate biopsy: data from SEER-Medicare. J Urol. 2011;186:1830-1834 Crossref.
-  The GLOBOCAN Project: GLOBOCAN estimated age-standardised incidence and mortality rates: Europe 2008 [fact sheet]. World Health Organization, International Agency for Research on Cancer Web site. http://globocan.iarc.fr/. Accessed February 14, 2011.
-  H.G. Welch, E.S. Fisher, D.J. Gottlieb, M.J. Barry. Detection of prostate cancer via biopsy in the Medicare-SEER population during the PSA era. J Natl Cancer Inst. 2007;99:1395-1400 Crossref.
-  A.R. Zlotta, R.K. Nam. To biopsy or not to biopsy—thou shall think twice. Eur Urol. 2012;61:1115-1117 Abstract, Full-text, PDF, Crossref.
-  J.J. Tosoian, B.J. Trock, P. Landis, et al. Active surveillance program for prostate cancer: an update of the Johns Hopkins experience. J Clin Oncol. 2011;29:2185-2190
-  A.E. Ross, S. Loeb, P. Landis, et al. Prostate-specific antigen kinetics during follow-up are an unreliable trigger for intervention in a prostate cancer surveillance program. J Clin Oncol. 2010;28:2810-2816 Crossref.
-  J.J. Tosoian, S. Loeb, A. Kettermann, et al. Accuracy of PCA3 measurement in predicting short-term biopsy progression in an active surveillance program. J Urol. 2010;183:534-538 Crossref.
-  Hoeks CMA, Schouten MG, Bomers JGR, et al. Three-tesla magnetic resonance–guided prostate biopsy in men with increased prostate-specific antigen and repeated, negative, random, systematic, transrectal ultrasound biopsies: detection of clinically significant prostate cancers. Eur Urol. In press. doi:10.1016/j.eururo.2012.01.047.
-  So C, Kirby KA, Mehta K, et al. Medical center characteristics associated with PSA screening in elderly veterans with limited life expectancy. J Gen Intern Med. In press.
-  S. Loeb, E.J. Metter, D. Kan, K.A. Roehl, W.J. Catalona. Prostate-specific antigen velocity (PSAV) risk count improves the specificity of screening for clinically significant prostate cancer. BJU Int. 2012;109:508-513 Crossref.
-  AUA Response to 2011 U.S. Preventive Services Task Force Draft Recommendations on Prostate Cancer Testing. American Urological Association Web site. http://www.auanet.org/content/health-policy/government-relations-and-advocacy/in-the-news/aua-response-to-uspstf.cfm?acid=7333870728|NE21Off717&WT.mc_id=NetNews7006. Accessed November 9, 2011.
-  M.J. Roobol, E.W. Steyerberg, R. Kranse, et al. A risk-based strategy improves prostate-specific antigen-driven detection of prostate cancer. Eur Urol. 2010;57:79-85 Abstract, Full-text, PDF, Crossref.
-  G. Trottier, M.J. Roobol, N. Lawrentschuk, et al. Comparison of risk calculators from the Prostate Cancer Prevention Trial and the European Randomized Study of Screening for Prostate Cancer in a contemporary Canadian cohort. BJU Int. 2011;108:E237-E244 Crossref.
-  van Vugt HA, Roobol MJ, Busstra M, et al. Compliance with biopsy recommendations of a prostate cancer risk calculator. BJU Int. In press.
-  M.J. Roobol, H.A. van Vugt, S. Loeb, et al. Prediction of prostate cancer risk: the role of prostate volume and digital rectal examination in the ERSPC risk calculators. Eur Urol. 2012;61:577-583 Abstract, Full-text, PDF, Crossref.
-  J. Hugosson, S. Carlsson, G. Aus, et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol. 2010;11:725-732 Crossref.
a Department of Urology, New York University, NY, USA
b Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands
© 2012 European Association of Urology, Published by Elsevier B.V.
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