The Value of an Extensive Transrectal Repeat Biopsy with Anterior Sampling in Men on Active Surveillance for Low-risk Prostate Cancer: A Comparison from the Randomised Study of Active Monitoring in Sweden (SAMS).

A systematic repeat biopsy is recommended for men starting on active surveillance for prostate cancer, but the optimal number and distribution of cores are unknown.

To evaluate an extensive repeat transrectal biopsy with anterior sampling in men starting on active surveillance.

Randomised multicentre trial. From 2012 to 2016, 340 Swedish men, aged 40-75yr, with recently diagnosed low-volume Gleason grade group 1 prostate cancer were included.

Either an extensive transrectal biopsy with anterior sampling (median 19 cores) or a standard transrectal biopsy (median 12 cores).

Primary outcome measure: Gleason grade group ≥2 cancer.

Cancer in anteriorly directed biopsy cores and postbiopsy infection. Nonparametric statistical tests were applied.

Gleason grade group ≥2 cancer was detected in 16% of 156 men who had an extensive biopsy and in 10% of 164 men who had a standard biopsy, a 5.7% difference (95% confidence interval [CI]-0.2% to 13%, p=0.09). There was a strong linear association between prostate-specific antigen (PSA) density and cancer in the anteriorly directed biopsy cores. The odds ratios for cancer in the anteriorly directed cores were for any cancer 2.2 (95% CI 1.3-3.9, p=0.004) and for Gleason grade group ≥2 cancer 2.3 (95% CI 1.2-4.4, p=0.015) per 0.1-ng/ml/cm3 increments. Postbiopsy infections were equally common in the two groups. A limitation is that magnetic resonance imaging was not used.

The trial did not support general use of the extensive transrectal repeat biopsy template, but cancer in the anteriorly directed cores was common, particularly in men with high PSA density. The higher the PSA density, the stronger the reason to include anterior sampling at a systematic repeat biopsy.

This trial compared two different templates for transrectal prostate biopsy in men starting on active surveillance for low-risk prostate cancer. Cancer was often found in the front part of the prostate, which is not sampled on a standard prostate biopsy.

European urology. 2019 Mar 13 [Epub ahead of print]

Ola Bratt, Erik Holmberg, Ove Andrén, Stefan Carlsson, Linda Drevin, Eva Johansson, Andreas Josefsson, Maria Nyberg, Jonas Sandberg, Pär Stattin, David Robinsson

Department of Urology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. Electronic address: ., Regional Cancer Centre, Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Gothenburg, Sweden., Department of Urology, Örebro University Hospital, Örebro, Sweden., Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden., Regional Cancer Centre, Uppsala-Örebro, Uppsala, Sweden., Department of Urology, Academic Hospital, Uppsala, Sweden., Department of Urology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden., Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden., Department of Urology, Norrland University Hospital, Umeå, Sweden., Department of Surgical Sciences, Uppsala University, Uppsala, Sweden., Department of Urology, Department of Urology, Jönköping County, Sweden.