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Volume 61, issue 6, pages e53-e66, June 2012

Prostate Cancer

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

Stacy Loeb a lowast , Suzanne van den Heuvel b, Xiaoye Zhu b, Chris H. Bangma b, Fritz H. Schroder b and Monique J. Roobol b

Published online 8 March 2012, pages 1117 - 1118

Full Text Full-Text PDF (70 KB)

Refers to article:

To Biopsy or Not to BiopsyThou Shall Think Twice

Alexandre R. Zlotta and Robert K. Nam

June 2012 (Vol. 61, Issue 6, pages 1115 - 1117)

Full Text Full-Text PDF (112 KB)

Refers to article:

Infectious Complications and Hospital Admissions After Prostate Biopsy in a European Randomized Trial

Stacy Loeb, Suzanne van den Heuvel, Xiaoye Zhu, Chris H. Bangma, Fritz H. Schröder and Monique J. Roobol

Accepted 28 December 2011

June 2012 (Vol. 61, Issue 6, pages 1110 - 1114)

Abstract Full Text Full-Text PDF (177 KB)

Article Outline

Our group recently reported an increasing frequency of hospitalizations after prostate biopsy [1] consistent with numerous international studies [2] and [3]. 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 [4]. 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 [5].

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 [6], 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 [7]. 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 [8] and [9]. 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 [10] 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 [11]. 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 [12].

There is an increasing shift away from “one size fits all” toward a risk-adapted screening approach [13]. 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) [14]. This tool has now been externally validated [15] 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 [16].

Recently, our group showed that prostate size estimates from DRE could be used in the model with only a slight impact on performance characteristics [17]. 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 [1]. 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 [18] 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.

Funding support

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).

References

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  • [2] 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
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  • [14] 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.
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Footnotes

a Department of Urology, New York University, NY, USA

b Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands

lowast Corresponding author. 550 1st Ave, VZ30 6th floor (#612), New York, NY 10016, USA. Tel. +1 646 501 2559.

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