The Impact of Complications After Initial Prostate Biopsy on Repeat Protocol Biopsy Acceptance Rate. Results from the Prostate Cancer Research International: Active Surveillance JAPAN Study

Over the last two decades, active surveillance (AS) has been established as a treatment strategy for favorable prostate cancers. This strategy is indicated for insignificant cancer, which is typically indolent with limited potential to progress and will not threaten life prognosis in the future. AS is a practical solution to avoid overtreatment for such insignificant cancer. To avoid missing the signs of disease progression, prostate-specific antigen (PSA) tests, digital rectal examinations, and repeat protocol biopsies have been the mainstay of AS follow-up protocols.

Because biomarkers and radiographic examinations are not accurate enough for the evaluation of cancer aggressiveness, for safer AS protocol execution, repeat protocol biopsy is mandatory. However, the acceptance rate of repeat protocol biopsy is not high enough. We assume that the major reason for low compliance is the burden of biopsy, especially complications.

We performed a retrospective analysis using a prospective cohort in the PRIAS-JAPAN study. In our results, out of 759 patients who proceeded to protocol at 1 year, repeat protocol biopsy non-acceptance rate at 1 year was 14.9%. Furthermore, pain at initial diagnostic biopsy was a significant predictor for repeat protocol biopsy non-acceptance (odds ratio 4.68, 95% confidence interval 1.864–11.75; p=0.001). This result is easy to understand being largely consistent with what we think of in our clinical practice. We believe that our study findings are meaningful for providers of AS in real-world clinical practice in the context of improving the compliance of further biopsies. Due to the limitation on data collection, information on the reason for non-acceptance of repeat biopsy at 1 year was lacking. Further studies are needed to improve the compliance of biopsy from the perspective of mental status and quality of life.

On the other hand, AS has the dilemma of a minimally invasive strategy for favorable prostate cancers but requiring an invasive examination, such as biopsy. Since AS protocols are strictly designed, we should always reevaluate whether we are following up too much for the patients. In this context, we need to pursue a protocol that is less invasive but still safe.

Written by: Yoichiro Tohi, MD, Department of Urology, Faculty of Medicine, Kagawa University, Takamatsu, Japan

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