Prostate Cancer Mortality in Men With a Negative Initial Biopsy

Gerald Chodak, MD


March 17, 2017

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Hello. I am Dr Gerald Chodak from Medscape. Today I want to talk about the implications of having one negative prostate biopsy. Klemann and coworkers[1] recently published an article based on the Danish Prostate Cancer Registry. They looked at more than 64,000 men who underwent a prostate biopsy between 1995 and 2011. They have follow-up through 2015, providing nearly 20 years of available data.

They found that for those men whose initial prostate biopsy was negative, only 2% eventually died from prostate cancer. The projected prostate cancer mortality in that group was about 5.2%. The odds of dying from other causes during that time was 23% in this group. Men who had a negative initial prostate biopsy were nearly 11 times more likely to die of causes other than prostate cancer.

About 11% of the men ultimately had a second biopsy. Even in that group, the mortality was low. The study also had data on about 22% of the men who had an initial PSA available. In the men whose PSA was 10 µg/mL or lower, the odds of dying from prostate cancer in that group, again, was only 1%.

Of the men who eventually underwent a second biopsy, the odds of being diagnosed with cancer and having a Gleason score of 8 were also extremely low, about 2+%. Some 19,000 men did not undergo a second biopsy, and the odds of dying from prostate cancer in this group was 1%.

These data are not based on men who underwent prostate cancer screening. Many of the men had only a six-core biopsy done at the time. When one looks at the European Randomized Study of Screening for Prostate Cancer (ERSPC),[2] where patients had screening PSAs, the data are relatively consistent with those findings.

What does this information mean for the patient, going forward? The median age in this study was 67 and the median follow-up was only 5.9 years, even though there were up to 20 years of follow-up. If a man has a life expectancy of 25 or 30 years for example, it is hard to know how these data will help make a decision going forward.

Men who are 67 or older, or those with a life expectancy of, for example, 10-15 years or even up to 20 years, should realize that their risk of dying from prostate cancer after one negative biopsy is extremely low, especially compared with their risk for mortality from other causes.

Does this mean that men should not undergo a second biopsy or follow-up? Not necessarily. Certainly, continued PSA levels are reasonable to do. If a man's PSA goes above 10 µg/mL, then another biopsy may be warranted. In terms of whether we should be overly aggressive with this group, that question is reasonable to ask.

It would appear that the value of doing MRI-guided biopsies after one negative biopsy may help find more cancer, but it also may result in overtreating many of these men because the risk of dying from prostate cancer is still very low. Going forward, the debate is going to continue—whether ultrasound-guided, random biopsies, or MRI-guided biopsies are the way to proceed. For now, I think it is useful information to advise a patient who has had one negative biopsy core set that his risk of dying from prostate cancer, even without another biopsy, is extremely low.

I look forward to your comments. Thank you.


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