Role of repeated biopsy of the prostate in predicting disease progression in patients with prostate cancer on active surveillance

BACKGROUND. Active surveillance (AS) with deferred treatment is an established management option for patients with prostate cancer and favorable clinical parameters. The impact of repeat biopsy after diagnosis was examined in a cohort of men with prostate cancer on AS. METHODS. In all, 186 men with prostate cancer with favorable parameters or who refused treatment were conservatively managed by AS. Of these, 92 patients had at least I biopsy after diagnosis. Patients were followed every 3 to 6 months with prostate-specific antigen (PSA) and physical examination and were offered rebiopsy annually or if there were any changes on physical examination or in the PSA value. Disease progression while on AS was defined as having >= 1 of the following: >= cT2b disease, >= 3 positive cores, >50% of cancer in at least I core, or a predominant Gleason pattern of 4 in rebiopsies. RESULTS. The median age of the patients at the time of diagnosis was 67 years (range, 49-78 years). The median follow-up was 76 months (range, 20-169 months). Of the 92 patients who underwent repeat biopsies, 42 patients, 25 patients, 13 patients, 10 patients, and 2 patients had 1, 2, 3, 4, and 5 rebiopsies, respectively. A total of 34 patients (36%) demonstrated disease progression on rebiopsy. The first rebiopsy was positive for cancer in 48 patients (52.2%) and negative in 44 patients (47.8%). The 5-year actuarial progression-free probability was 82% for patients with a negative first repeat biopsy compared with 50% for patients with a positive first rebiopsy (P = .02). A PSA doubling time <67 months was associated an increased risk of disease progression on biopsy. CONCLUSIONS. Negative rebiopsy in patients with prostate cancer on AS is associated with low-volume disease. The result of first repeated biopsy appears to have a strong impact on disease progression. Patients with a positive first repeated biopsy should be considered for treatment. An intensive biopsy protocol within the first 2 years is required to identify and treat those patients.