A Comparison of Periodic Rebiopsy versus Patient-Based Rebiopsy in Prostate Cancer Active Surveillance

Abstract

Introduction

In low-risk prostate cancer (PCa), the aim of active surveillance (AS) is to reduce overtreatment and avoid potential adverse effects. The rebiopsy approach in AS remains debated, spanning routine scheduled biopsies to clinically- or imaging-driven rebiopsies based on PSA kinetics or multiparametric MRI (mpMRI). In this retrospective, single-center comparative cohort study, we examined outcomes of periodic vs patient-based rebiopsy during AS and evaluated oncological outcomes in patients with PCa.

Methods

Seventy-four patients who underwent at least one year of AS for PCa between January 2019 and July 2024 were retrospectively analyzed. Two distinct AS protocol patients were included in the study from 4 different physicians in our clinic. Demographic data, PSA levels, PSA kinetics, mpMRI findings, and rebiopsy pathology results were documented. Radical prostatectomy (RP) pathology results and factors influencing definitive treatment (DT) decisions were compared between the 2 groups: periodic rebiopsy (n = 41), and patient-based rebiopsy (n = 33).

Results

The median rebiopsy time was shorter in the periodic group (12.5 months, IQR: 1) than in the patient-based group (14 months, IQR: 9; P < 0.001). First-year rebiopsies were more frequent in the periodic group (68.3%) than in the patient-based group (45.5%; P = 0.048). No significant difference in DT switching rates or final pathology outcomes was observed, though patients in the periodic group switched to DTs earlier (P = 0.045). A positive Spearman’s correlation was identified between the maximum PSA density and the International Society of Urological Pathology (ISUP) score of RP specimens [rho = 0.62, P = 0.001]. A PSA density cut-off value of ≥0.17 ng/mL² was found to predict an ISUP grade ≥2 in the final pathological assessment with high accuracy (AUC = 0.891, 95% CI: 0.753-1.00, P = 0.003).

Conclusions

Patient-based rebiopsy protocols driven by PSA kinetics and mpMRI results can minimize unnecessary procedures, prevent overtreatment, and optimize monitoring in AS of PCa.

Keywords

active surveillance mpMRI prostate biopsy prostate cancer PSA

Introduction

Definitive treatments such as RP and radiotherapy (RT) are commonly used to treat localized and locally advanced PCa. However, these DTs can cause serious urinary and gastrointestinal complications, particularly permanent urinary incontinence, and erectile dysfunction.¹ AS treatment has gained popularity over the past two decades² for this slowly progressing cancer, which usually takes more than 10 years from disease onset to death even in untreated patients.^2,3 Several studies of patients with localized prostate cancer who have not undergone local treatment with a follow-up period of up to 25 years are available, and overall survival (OS) and cancer-specific survival (CSS) as endpoints.⁴

The objective of AS for localized, low-risk prostate cancer is to reduce overtreatment and minimize the adverse side effects of DTs, such as urinary incontinence, erectile dysfunction, strictures, and other lower urinary tract symptoms while maintaining the option of curative treatment at the first sign of disease progression, in patients with a life expectancy of more than 10 years.^5,6 There is considerable variation and heterogeneity between studies regarding follow-up policies in AS, including the frequency of mpMRI and repeat prostate biopsies (rebiopsy). Additionally, there is considerable variation in the timing of DTs and the prioritization of outcome measures.^7-10

The majority of clinical follow-up methods involve the measurement of prostate-specific antigen (PSA) level at intervals of 3-6 months, a digital rectal examination at 6-12-month intervals, mpMRI at yearly intervals, and repeated prostate biopsies (rebiopsies) at 1-2-year intervals.^11,12 In the event of cancer progression, DT is initiated.

Complications such as sepsis and even death can occur rarely after a prostate biopsy. Some patients with PCa in the AS protocol may prefer DTs at their request without rebiopsy or clinical cancer progression.^6,13 Furthermore, in clinical practice, some patients who are recommended to undergo rebiopsy opt for DTs by avoiding rebiopsy.¹⁰ Ongoing studies are investigating the efficacy of AS protocols based on mpMRI and PSA kinetics (patient-based rebiopsy). This approach may allow for postponing rebiopsies, thereby reducing the risk of complications.¹⁴ In addition, recent advancements in computational methods and prognostic models have enhanced PCa management. Mortality rate estimation models for PCa patients, integrating clinical and demographic data to predict outcomes, complement traditional clinical assessments and inform AS protocols.¹⁵

This study aimed to examine the results of periodic and patient-based rebiopsy in AS and to evaluate the oncological outcomes of our AS patients in comparison to those in the literature.

Materials and Methods

Patient Selection and Active Surveillance Criteria

Following approval from the local Ethics Committee (Ethics Committee of Health Sciences University, Antalya Training and Research Hospital; Approval date: 08.08.2024; Approval No: 11/23; retrospectively registered), data from patients who underwent AS for prostate cancer (PCa) and who were followed up at our clinic between January 2019 and July 2024 were evaluated retrospectively. The patient consent forms obtained during follow-up and procedures already included information indicating that patient data might be used in future studies; accordingly, the requirement for additional informed consent was waived by our Institutional Review Board (IRB). Patients were included in the AS protocols without any confirmation biopsy from the date of initial diagnosis. Patients who reached at least 1 year of AS were included in the study. The AS criteria were PSA ≤10 ng/mL, International Society of Urological Pathology (ISUP) grade <2, number of tumor-positive prostate biopsy cores ≤2, tumor rate in positive cores ≤50%, and T stage ≤2b.⁶ All initial and rebiopsies were conducted by transrectal systematic biopsy with a mpMRI-directed cognitive fusion biopsy.¹⁶ Patients with incomplete data, PCa diagnosed after repeated biopsies, AS <1 year, or extensive disease on mpMRI at diagnosis were excluded.

A total of 74 patients were included in the study. Two distinct AS protocols patients were included in the study (periodic rebiopsy group, n = 41; patient-based rebiopsy group, n = 33) from 4 different physicians in our clinic. The first is a periodic rebiopsy protocol, in which periodic rebiopsy is performed at regular intervals during the first and third years of AS, regardless of mpMRI and PSA kinetics. The second is a patient-based rebiopsy protocol, in which rebiopsy is performed in patients suspected of clinical cancer progression in follow-up based on digital rectal examination, mpMRI, and PSA kinetics. A rebiopsy was recommended for patients in the patient-based rebiopsy group, who demonstrated an increase in PSA kinetics (a PSA doubling time ≤3 years, a PSA velocity ≥0.75 ng/mL/year or a PSA density ≥0.15 ng/mL²) in repeated measurements during AS^17,18; disease progression above T2b on digital rectal examination, a greater number of lesions in the prostate imaging-reporting and data system (PIRADS) 3 or above on mpMRI; and an increase in the size of PIRADS 3 or above lesions or extensive disease on mpMRI.¹⁴ Patients declining rebiopsy but not transitioning to DT were categorized in the patient-based group if they met AS criteria according to PSA kinetics, mpMRI findings, etc.; otherwise, they were excluded from the study.

Collected Data of AS Patients and Rebiopsy Protocols

The demographic data of the patients, serum PSA levels and PSA densities at the time of PCa diagnosis, pathological results of the initial biopsy and rebiopsy, highest PSA levels and highest PSA densities during the AS period, mpMRI reports, and factors that prompted patients to switch to DT were documented. Patients who declined to undergo rebiopsy were advised to receive a DT without rebiopsy in both groups. The effective factors for switching to DTs were determined as follows: patient decision without disease progression; patient decision with clinical disease progression without rebiopsy (according to PSA kinetics and mpMRI); and disease progression as a result of rebiopsy. The final pathology results of patients who underwent RP were noted. AS treatment was terminated for patients who switched to DTs. A comparative analysis was conducted to examine the data across the groups. The reporting of this retrospective cohort study follows the STROBE guidelines.¹⁹ Throughout the study, all patient data were anonymized, and no personal identifiable information was disclosed.

Statistical Analysis

A power analysis was conducted to determine the sample size required to detect a significant difference in rebiopsy timing between groups (effect size = 0.5, α = 0.05, power = 0.8), estimating a minimum of 32 patients per group. The Shapiro- Wilk test assessed normality of continuous variables. Normally distributed variables (eg, age, PSA levels) were analyzed with Independent sample t-tests and reported as mean ± standard deviation (SD). Non-normally distributed variables (eg, rebiopsy time, PSA density) were analyzed with Mann-Whitney U tests and reported as median (IQR). Categorical data were analyzed using Pearson’s chi-square test or Fisher’s exact test, reported as numbers and percentages. Spearman’s correlation was used for non-normally distributed variables due to skewed distributions. Receiver operating characteristic (ROC) curve analysis was employed to determine the optimal cutoff values of PSA density for predicting final pathology results, using the Youden index to optimize sensitivity and specificity. Interobserver variability among physicians was minimized through standardized AS protocols and joint case reviews. mpMRI interpretations were performed by radiologists blinded to clinical data. A P-value <0.05 indicated statistical significance. Analyses were conducted using IBM SPSS version 22 for Windows (Armonk, NY: IBM Corp., USA).

The Use of Artificial Intelligence

During the preparation of this work, the authors utilized OpenAI’s ChatGPT to generate summaries of research articles related to the topic and English language editing. These summaries were evaluated by comparing them to manually written summaries by experts in the field. Upon confirming the accuracy and relevance of the generated summaries, they were integrated into the literature review section of the manuscript. After carefully reviewing and editing the content as necessary, full responsibility for the publication’s content is taken by the authors.

Results

No significant differences were observed in age, BMI, prostate volume, PSA levels, PSA densities, or mpMRI findings, at diagnosis between the periodic rebiopsy and patient-based rebiopsy groups (P > 0.05). The AS follow-up period was 14 (IQR:9) months in the periodic rebiopsy group and significantly shorter than the patient-based rebiopsy group (20 months IQR:15), (P = 0.009). No significant differences were observed in the maximum PSA levels, maximum PSA densities, or repeated mpMRI findings, during follow-up between the groups (P > 0.05). Rebiopsy time was 12.5 (IQR:1) months in the periodic rebiopsy group and significantly shorter than the patient-based rebiopsy group (14 months IQR:9), (P < 0.001). A total of 28 (68.3%) patients in the periodic rebiopsy group underwent rebiopsy at first year. A total of 15 (45.5%) patients in the patient-based rebiopsy group underwent rebiopsy during AS (P = 0.048). While no patient in the patient-based rebiopsy group underwent a second biopsy, 4 patients in the periodic rebiopsy group underwent a second rebiopsy at the 36-month follow-up mark. The second rebiopsy pathology results demonstrated that 2 patients exhibited tumor-free, while 2 patients exhibited ISUP grade 1 in 2 cores. Additionally, it was determined that patients in the periodic rebiopsy group underwent to DTs earlier (P = 0.045). Nevertheless, no significant difference was observed in the rates of switching to DTs between the groups (P = 0.984) (Table 1).

Table 1.

Clinical Characteristics of Active Surveillance Patients

		Overall AS patients (n = 74)	Periodic rebiopsy (n = 41)	Patient-based rebiopsy (n = 33)	P-value
Age (years)		63.85±5.88	63.05±5.30	64.85±6.47	0.193
BMI (kg/m², IQR)		27.70 (5.97)	28.07 (5.27)	26.60 (6.81)	0.476
PSA level at the diagnosis (ng/ml)		5.50 ±1.23	5.39 ±1.28	5.63 ±1.17	0.403
Prostate volume at the diagnosis (ml, IQR)		50 (24)	55 (27)	50 (23)	0.823
PSA density at the diagnosis (ng/ml², IQR)		0.10 (0.04)	0.09 (0.04)	0.11 (0.04)	0.141
PIRADS scores in mpMRI at the diagnosis (IQR)		3 (3)	3 (2)	3 (3)	0.648
Follow up time (months, IQR)		17.0 (10.3)	14 (9)	20 (15)	0.009
Maximum PSA level at the follow up (ng/ml, IQR)		6.90 (2.64)	6.69 (2.59)	7.22 (3.17)	0.284
Maximum PSA density at the follow up (ng/ml², IQR)		0.13 (0.07)	0.12 (0.04)	0.16 (0.09)	0.181
New finding in mpMRI (n,%)	Yes	23 (31.1)	12 (29.3)	11 (33.3)	0.707
New finding in mpMRI (n,%)	No	51 (68.9)	29 (70.7)	22 (66.7)
Rebiopsy time (months, IQR)		13 (2)	12.5 (1)	14 (9)	<0.001
Rebiopsy (n,%)	Yes	43 (58.1)	28 (68.3)	15 (45.5)	0.048
Rebiopsy (n,%)	No	31 (41.9)	13 (31.7)	18 (54.5)
Rebiopsy pathological results (n,%)	Tumor-free	21 (48.8)	15 (53.6)	6 (40.0)	0.396
Rebiopsy pathological results (n,%)	ISUP 1	22 (51.2)	13 (46.4)	9 (60.0)
Patients underwent DT (n,%)		27 (36.5)	15 (36.6)	12 (36.4)	0.984
DT time (months, IQR)		14 (5)	13 (2.0)	16 (19.5)	0.045

AS: active surveillance, BMI: body mass index, PSA: prostate specific antigen, PIRADS: prostate imaging-reporting and data system, IQR: interquartile range, mpMRI: multiparametric magnetic resonance imaging, ISUP: International Society of Urological Pathology, DT: definitive treatment.

Bold indicates statiscially significant values.

The rebiopsy results (ISUP grade ≥2, number of tumor-positive cores ≥3, tumor rate in positive cores ≥50% or T stage ≥2c) provided to the decision that only 1 (2.4%–3.0%) patient in each group should undergo DTs. No significant difference was found between the groups in terms of switching factors to DTs. Among the patients who switched to DTs, 7 (17.1%) patients in periodic rebiopsy group and 10 (30.3%) patients in patient-based rebiopsy group declined rebiopsy following progression in PSA level, PSA kinetics, or mpMRI and subsequently switched to DTs. No statistically significant differences were observed between the final pathological results of the groups (P > 0.05) (Table 2). However, a positive correlation was identified between the maximum PSA density and >pT2C stage disease in the final RP pathology result [rho = 0.53, P = 0.008]. Also, a positive correlation was identified between the maximum PSA density and final pathology ISUP score [rho = 0.62, P = 0.001]. A PSA density cut-off value of ≥0.17 ng/mL² during follow-up was identified as a significant predictor of an ISUP grade ≥2 in the final pathological assessment (AUC = 0.891, 95% CI: 0.753-1.00, P = 0.003). Similarly, a PSA density threshold of ≥0.18 ng/mL² was found to be predictive of a pathological T stage ≥T2c (AUC = 0.833, 95% CI: 0.651-1.00, P = 0.016).

Table 2.

Definitive Treatment Decision Factors and Final Patological Results of the Groups

		Periodic Rebiopsy (n = 41)	Patient-Based Rebiopsy (n = 33)	P-value
DT decision factors (n,%)	Rebiopsy result	1 (2.4)	1 (3.0)	0.141
	Patient decision	7 (17.1)	1 (3.0)
	Clinical progression according to PSA level and kinetics, and mpMRI	7 (17.1)	10 (30.3)
DT (n,%)	Radical prostatectomy	14 (34.2)	10 (30.3)	0.984
DT (n,%)	Radiotheraphy	1 (2.4)	2 (6.0)	0.984
Final pathological ISUP grade (n,%)	ISUP 1	11 (78.6)	6 (60.0)	0.334
Final pathological ISUP grade (n,%)	ISUP 2	3 (21.4)	4 (40.0)	0.334
Final pathological T stage (n,%)	T2a	8 (57.1)	5 (50.0)	0.913
	T2b	2 (14.3)	3 (30.0)
	T2c	3 (21.4)	2 (20.0)
	T3a	1 (7.1)	0

DT: definitive treatment, ISUP: International Society of Urological Pathology.

Discussion

Trends in Active Surveillance

The AS rate in low-risk PCa patients increased from 26.5% in 2014 to 59.6% in 2021 in the U. S.²⁰ In light of the balance between the benefits and the potential complications of DTs, AS represents a crucial strategy for PCa management. The primary advantage of AS is the prevention or postponement of adverse effects associated with traditional PCa therapies.^5,6 It is estimated that the majority of men with AS may never require definitive therapies and can maintain their quality of life without the burden of complications associated with DTs.¹⁰ It has been documented that almost half of the men who underwent AS receive a DT within 4 years. Moreover, PSA progression, mpMRI and rebiopsy results, and patient preference are determinants of DTs decisions.¹³ However, the extent to which rebiopsy results alone are effective is unclear. Despite the increased frequency of rebiopsy in the periodic rebiopsy protocol, there was no significant difference in the rates of switching to DTs or in the final pathology results. Conversely, it prompted the patients who avoid rebiopsy to switch to DTs earlier. The findings of the present study suggest that periodic rebiopsy in AS did not offer any additional benefits. Conversely, patient-based rebiopsy according to the PSA kinetics and mpMRI results may be more instrumental in avoiding unnecessary rebiopsies in AS.

It is of the utmost importance in AS that the initial diagnosis and ongoing assessment of cancer status are as accurate as possible. The generally accepted AS criteria in systemic reviews are reported as PSA ≤10 ng/mL, ISUP grade <2, tumor-positive prostate biopsy core count ≤2, tumor-to-positive core ratio ≤50%, and T stage ≤2b. The Movember consensus group agrees that the ISUP grade group and mpMRI are the most important criteria for determining eligibility for AS.⁸ The present study’s AS criteria were designed based on the aforementioned criteria.

Repeated PSA tests, digital rectal examinations, prostate MRI, and periodic rebiopsies in AS patients can be sources of anxiety. Additionally, that PCa may advance or become more malignant in AS. Furthermore, the psychological impact of being diagnosed with cancer may prompt some patients to opt for DT despite the low probability of progression, rather than living with uncertainty.¹³

Rebiopsy Protocols and Clinical Outcomes

Rebiopsy and multiparametric MRI play significant roles in the management of AS, as they provide direct information on the stability or progression of the disease. Rebiopsy allows for re-evaluation of the ISUP grade and the PCa risk group.^6-9,11,12 Although rebiopsy is recommended on an annual or biennial basis during AS, recent studies have demonstrated that this interval can be safely extended. In a study of 300 patients undergoing AS, Kovac et al demonstrated that 84% of patients exhibited stable disease in the second year of rebiopsy. Moreover, when the second-year rebiopsy was postponed by a period of 5 years, the biochemical recurrence-free survival rate was 89%. The authors proposed that less invasive methods may be preferable for the follow-up of AS patients.²¹ However, no study has examined the relationship between rebiopsy time and cancer-specific survival in patients who underwent AS.

Furthermore, discrepancies may exist between the pathology results of prostate biopsy and the final pathology results of RP. A comprehensive analysis of 1325 PCa patients revealed that the final pathological grade of the RP specimen was altered in 452 patients (34.1%). The ISUP grade group increased in 359 patients and decreased in 93 patients. Upon re-evaluation of biopsy samples from patients in the highest ISUP grade group by experienced urological pathologists, the concordance rate between the final surgical ISUP grade group increased from 34.8% to 50%.²² These findings underscore the significance of expert evaluation of pathological specimens. Additionally, Ciccone et al¹³ indicated that an independent review of prostate biopsy specimens (OR, 2.35; 95% CI, 1.26-4.38) and a multidisciplinary assessment (OR, 2.65; 95% CI, 1.38-5.11] were associated with the selection of AS over any active treatment.

In up to 56% of AS patients, cancer cannot be sampled via rebiopsy, and pathological results can be classified as tumor-free.²³ The management of tumor-free rebiopsy patients with AS treatment presents a distinct set of challenges. The periodic rebiopsy group exhibited a higher rate of tumor-free rebiopsy pathology than the patient-based rebiopsy group (53.6% vs 40%, P > 0.05). The tumor-free and ISUP 1 results from the second rebiopsy in the periodic biopsy group are not clinically significant, as they do not warrant DT. This finding supports the hypothesis that patient-based rebiopsies can reduce the number of unnecessary procedures.

Minor complications, including hematuria (58%), rectal bleeding (10%–37%), and hypogastric pain, are frequently reported following prostate biopsy. Acute prostatitis and septic complications have been observed in 5% of patients.²⁴ One patient in the periodic rebiopsy group developed acute prostatitis following rebiopsy. It is clear that the discomfort and complications associated with biopsy have led to a decline in the acceptance rates of rebiopsies among AS patients over time.¹⁰ A total of 17 (23%) patients declined to undergo rebiopsy according to our results.

The financial and resource implications of periodic rebiopsies can present a further challenge. The necessity for periodic rebiopsies also places additional pressure on healthcare facilities, which may result in extended waiting times and an overall reduction in patient management efficiency in AS programs. Furthermore, there is a concern that periodic rebiopsies may affect the incidence of complications and the functional outcomes of RP. Nevertheless, studies have indicated that the mean time to RP following biopsy is approximately 3 months.²⁵ In our clinic, a waiting period of 2 months is generally accepted before proceeding with the RP operation after prostate biopsy.

Role of PSA Kinetics and mpMRI

There are also studies demonstrating the feasibility of AS with prostate MRI, which avoids periodic rebiopsies and complications.²⁶ Furthermore, PSA kinetics, including PSA level, PSA doubling time, PSA velocity, and PSA density, have been extensively examined as potential predictors of cancer progression in AS patients. In numerous AS programs, PSA kinetics have been employed as a trigger for initiating intervention.^9,12,17,18 The Prostate Cancer Radiological Estimation of Change In Sequential Evaluation (PRECISE) criteria were established to standardize the assessment of tumor progression on repeated MRI as a predictor of histological upgrading.²⁷ The DETECTIVE consensus study showed that periodic rebiopsy can be omitted if MRI and PSA kinetics are stable.⁹ In addition, O’Connor et al²⁸ suggested that patients who are stable (PRECISE criteria 3) on repeat MRI during AS and have a low PSA density (<0.15), have very low progression rates; therefore, repeat biopsy may be omitted. Patel et al²⁹ demonstrated that patients with a PSA velocity above 0.4 ng/mL/year exhibited a markedly elevated risk of rebiopsy following the initial 2 years of AS. In light of these findings, AS patients with stable disease may evade rebiopsy for an extended period of time, as indicated by the monitoring of PSA kinetics. Nevertheless, in poorly differentiated PCa patients with relatively low PSA secretion, cancer progression may not correlate with PSA kinetics.³⁰ In such patients, rebiopsy decision based on PSA kinetics may lead to insidious disease progression and delay of DTs. If periodic rebiopsy is not performed in AS patients, disease monitoring via mpMRI in addition to PSA kinetics seems mandatory.

Advanced Diagnostic - Computational Methods

Moreover, current studies suggest that DTs can be performed even without prior prostate biopsy for pathological cancer diagnosis, with the increased positive prediction rate of conventional and molecular imaging methods. Wang et al treated 57 PCa patients by radical prostatectomy without prior prostate biopsy based on a noninvasive diagnostic strategy consisting of a diagnostic prediction model (comprised of the PIRADS score and PSA density) and the 18F-prostate-specific membrane antigen (PSMA)-1007 positron emission tomography (PET) examination. The minimum PSA density level of the 57 patients was 0.42 ng/mL², and all patients had a PIRADS score of 4 or above. The median SUV max of 18F-PSMA-1007 PET/CT was 21.6 (15.8-33.0). The positive predictive value of clinically significant PCa was 98.2%. Conversely, only 1.8% of patients were diagnosed with clinically insignificant PCa (ISUP grade = 1, Gleason score = 3 + 3), and no false positive results were observed.³¹

Molecular methods may also prove useful in rebiopsy decisions in patients with AS. Ki-67 is a nuclear protein of the cell cycle. High Ki-67 expression is associated with aggressive and invasive PCa.³² Therefore, periodic rebiopsies may be indicated for AS patients with high Ki-67 expression independent of PSA kinetics. Incorporating genetic and molecular testing into the decision-making process for DT is becoming increasingly prevalent. This approach may offer a more personalized approach to PCa management.

The retrospective nature of this study, the short AS period, and the limited number of patients involved render generalizations difficult and represent the limitations of the study. Furthermore, given that patients were followed by multiple physicians, differences in clinical decision-making processes may have influenced the results. The fact that the study was conducted at a single center limits the external validity of the findings.

Conclusions

A more individualized approach to rebiopsy timing may be warranted. Instead of adhering to rigid protocols for periodic rebiopsies in AS, clinicians may consider a more dynamic monitoring strategy that emphasizes PSA kinetics and mpMRI results to better guide treatment decisions while minimizing unnecessary invasive procedures.

Footnotes

ORCID iDs

Murat Sambel

Sahin Kilic

Eray Ozturk

Talip Kahilogullari

Yigit Demir

Deniz Bayar

Oguz Ergin

Ethical Considerations

The protocol for this research project has been approved by a suitably constituted Ethics Committee (Ethics Committee of Health Sciences University, Antalya Training and Research Hospital; Approval date: 08.08.2024; Approval No: 11/23), and it conforms to the provisions of the Declaration of Helsinki.

Consent to Participate

The patient consent forms obtained during follow-up and procedures already included information indicating that patient data might be used in future studies; accordingly, the requirement for additional informed consent was waived by our Institutional Review Board (IRB). Throughout the study, all patient data were anonymized and no personally identifiable information was disclosed.

Author Contributions

SK, MS: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Supervision; Validation; Visualization; Writing-original draft. SK, YD, TK, EO, DB: Data curation; Formal analysis, Investigation; Resources. SK, OE, MS, AE: Conceptualization; Investigation; Methodology; Resources; Supervision; Validation; Writing-review & editing. All authors reviewed the manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data of patients and statistical analysis data used to support the findings of this study are available from the corresponding author upon request.*

References

Corsini

Bergengren

Carlsson

, et al. Patient-reported side effects 1 year after radical prostatectomy or radiotherapy for prostate cancer: a register-based nationwide study. Eur Urol Oncol. 2024;7(3):605-613.

Hagmann

Ramakrishnan

Tamalunas

, et al. Two decades of active surveillance for prostate cancer in a single-center cohort: favorable outcomes after transurethral resection of the prostate. Cancers (Basel). 2022;14(2):368.

Horm

Sondik

. Person-years of life lost due to cancer in the United States, 1970 and 1984. Am J Publ Health. 1989;79(11):1490-1493.

Alam

Kumar

Norez

, et al. Natural history, and impact of surgery and radiation on survival outcomes of men diagnosed with low-grade prostate cancer at ≤ 55 years of age: a 25-year follow-up of > 60,000 men. Int Urol Nephrol. 2023;55(2):295-300.

Bruinsma

Nieboer

Roobol

, et al. Risk-based selection for active surveillance: results of the movember foundation’s global action plan prostate cancer active surveillance (GAP3) initiative. J Urol. 2021;206(1):62-68.

Cornford

van den Bergh

RCN

Briers

, et al. EAU-EANM-ESTRO-ESUR-ISUP-SIOG guidelines on prostate Cancer-2024 update. Part I: screening, diagnosis, and local treatment with curative intent. Eur Urol. 2024;86(2):148-163.

Bruinsma

Roobol

Carroll

, et al. Expert consensus document: semantics in active surveillance for men with localized prostate cancer-results of a modified Delphi consensus procedure. Vol. 14. In: Nature Reviews Urology. Nature Publishing Group; 2017:312-322.

Moore

King

Withington

, et al. Best current practice and research priorities in active surveillance for prostate Cancer-A report of a movember international consensus meeting. Eur Urol Oncol. 2023;6(2):160-182.

Lam

TBL

MacLennan

Willemse

PPM

, et al. EAU-EANM-ESTRO-ESUR-SIOG prostate cancer guideline panel consensus statements for deferred treatment with curative intent for localised prostate cancer from an international collaborative study (DETECTIVE study). Eur Urol. 2019;76:790-813.

10.

Kato

Matsumoto

Yokomizo

, et al. Outcomes of active surveillance for Japanese patients with prostate cancer (PRIAS-JAPAN). BJU Int. 2024;134(4):652-658.

11.

Chu

Lonergan

Washington

, et al. Multiparametric magnetic resonance imaging alone is insufficient to detect grade reclassification in active surveillance for prostate cancer. Eur Urol. 2020;78(4):515-517.

12.

Willemse

PPM

Davis

Grivas

, et al. Systematic review of active surveillance for clinically localised prostate cancer to develop recommendations regarding inclusion of intermediate-risk disease, biopsy characteristics at inclusion and monitoring, and surveillance repeat biopsy strategy. Eur Urol. 2022;81:337–346.

13.

Ciccone

De Luca

Oderda

, et al. START Collaborative Group. Patient and context factors in the adoption of active surveillance for low-risk prostate cancer. JAMA Netw Open. 2023;6:E2338039.

14.

Gallagher

Christopher

Cameron

, et al. Four-year outcomes from a multiparametric magnetic resonance imaging (MRI)-Based active surveillance programme: PSA dynamics and serial MRI scans allow omission of protocol biopsies. BJU Int. 2019;123(3):429-438.

15.

Kraujalis

Ruzgas

Milonas

. Mortality rate estimation models for patients with prostate cancer diagnosis. Baltic J. Modern Computing. 2022;10(2):170-184.

16.

Chang

Ghai

Kim

Oto

Giganti

Moore

. Mri targeted prostate biopsy techniques: ajr expert panel narrative review. AJR Am J Roentgenol. 2021;217:1263–1281.

17.

Ali

Gunnar

Jan-Erik

Hans

Pär

Jonas

. PSA doubling time predicts the outcome after active surveillance in screening-detected prostate cancer: results from the European randomized study of screening for prostate cancer, Sweden section. Int J Cancer. 2007;120(1):170-174.

18.

Nelson

Javier-DesLoges

Deka

, et al. Association of prostate-specific antigen velocity with clinical progression among African American and non-hispanic white men treated for low-risk prostate cancer with active surveillance. JAMA Netw Open. 2021;4(5):e219452.

19.

von Elm

Altman

Egger

Pocock

Gøtzsche

Vandenbroucke

STROBE Initiative . The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008;61:344-349.

20.

Cooperberg

Meeks

Fang

Gaylis

Catalona

Makarov

. Time trends and variation in the use of active surveillance for management of low-risk prostate cancer in the US. JAMA Netw Open. 2023;6(3):E231439.

21.

Kovac

Lieser

Elshafei

Jones

Klein

Stephenson

. Outcomes of active surveillance after initial surveillance prostate biopsy. J Urol. 2017;197(1):84-89.

22.

Okubo

Yamamoto

Sato

, et al. Diagnostic significance of reassessment of prostate biopsy specimens by experienced urological pathologists at a high-volume institution. Virchows Arch. 2022;480(5):979-987.

23.

King

Livermore

Laurila

TAJ

Huang

Jarrard

. Impact of immediate TRUS rebiopsy in a patient cohort considering active surveillance for favorable risk prostate cancer. Urol Oncol. 2013;31(6):739-743.

24.

Madej

Wilkosz

Rózański

Lipiński

. Complication rates after prostate biopsy according to the number of sampled cores. Cent European J Urol. 2012;65(3):116-118.

25.

Aas

Fosså

Kvåle

, et al. Is time from diagnosis to radical prostatectomy associated with oncological outcomes? World. J Urol. 2019;37(8):1571-1580.

26.

Valentin

Arsov

Ullrich

, et al. Magnetic resonance imaging-guided active surveillance without annual rebiopsy in patients with grade group 1 or 2 prostate cancer: the prospective PROMM-AS study. Eur Urol Open Sci. 2024;59:30-38.

27.

Moore

Giganti

Albertsen

, et al. Reporting magnetic resonance imaging in men on active surveillance for prostate cancer: the PRECISE recommendations—A report of a European school of oncology task force. Eur Urol. 2017;71(4):648-655.

28.

O’Connor

Wang

Yerram

, et al. Changes in magnetic resonance imaging using the prostate cancer radiologic estimation of change in sequential evaluation criteria to detect prostate cancer progression for men on active surveillance. Eur Urol Oncol. 2021;4(2):227-234.

29.

Patel

Feng

Landis

Trock

Epstein

Carter

. Prostate specific antigen velocity risk count predicts biopsy reclassification for men with very low risk prostate cancer. J Urol. 2014;191(3):629-637.

30.

Shindo

Ohuchida

Moriyama

, et al. A rare case of PSA-Negative metastasized prostate cancer to the stomach with serum CEA and CA19-9 elevation: a case report. Surg Case Rep. 2020;6(1):303.

31.

Wang

Xie

Yuan

, et al. Radical prostatectomy without prostate biopsy based on a noninvasive diagnostic strategy: a prospective single-center study. Prostate Cancer Prostatic Dis. 2025;28(2):496-502.

32.

Maia

Dos Santos

Reis

, et al.

Can we use Ki67 expression to predict prostate cancer aggressiveness?

Rev Col Bras Cir. 2022;49:e20223200.