Role of Repeated Biopsy of the Prostate inPredicting Disease Progression in PatientsWith Prostate Cancer on Active Surveillance

Mohammed Al Otaibi, MD1

Philip Ross, MD1

Nader Fahmy, MD1

Suganthiny Jeyaganth, MsC1

Helen Trottier, PhD2

Kanishka Sircar, MD3

Louis R. B�egin, MD3

Luis Souhami, MD4

Wassim Kassouf, MD1

Armen Aprikian, MD1

Simon Tanguay, MD1

1 Division of Urology, Department of Surgery,McGill University Health Center, Montreal, Que-bec, Canada.

2 Division of Cancer Epidemiology, McGill Univer-sity Health Center, Montreal, Quebec, Canada.

3 Department of Pathology, McGill UniversityHealth Center, Montreal, Quebec, Canada.

4 Department of Radiation Oncology, McGill Uni-versity Health Center, Montreal, Quebec, Canada.

BACKGROUND. Active surveillance (AS) with deferred treatment is an established

management option for patients with prostate cancer and favorable clinical pa-

rameters. 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 1 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 1 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 rebiop-

sies, respectively. A total of 34 patients (36%) demonstrated disease progres-

sion 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 com-

pared with 50% for patients with a positive first rebiopsy (P 5 .02). A PSA dou-

bling time <67 months was associated an increased risk of disease progression

on biopsy.

CONCLUSIONS. Negative rebiopsy in patients with prostate cancer on AS is asso-

ciated 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. Cancer

2008;113:286–92. � 2008 American Cancer Society.

KEYWORDS: prostate cancer, active surveillance, prostatic biopsy, disease pro-gression.

P rostate cancer remains the most common cancer in men. With

a progressive decrease in the prostate-specific antigen (PSA)

threshold leading to prostate biopsy, there exists significant stage

migration with an earlier prostate cancer diagnosis.1–3 This new rea-

lity leads to the more frequent diagnosis of cancer judged to be

potentially insignificant. The prevalence of prostate cancer in men

aged >50 years has been estimated to be as high as 40%.4–7 A large

proportion of these cancers are potentially insignificant and if left

Address for reprints: Simon Tanguay, MD, Divisionof Urology, Department of Surgery, McGill Univer-sity Health Center, 1650 Cedar Avenue, L8-318,Montreal, QC H3G 1A4, Canada; Fax: (514) 934-8297; E-mail: simon.tanguay@mcgill.ca

Received December 11, 2007; revision receivedFebruary 25, 2008; accepted March 6, 2008.

ª 2008 American Cancer SocietyDOI 10.1002/cncr.23575Published online 16 May 2008 in Wiley InterScience (www.interscience.wiley.com).

286

untreated may not necessarily impact an individual

patient’s survival or quality of life.8–10

During the PSA era, a man’s lifetime risk of being

diagnosed with prostate cancer has risen from 9% to

17%.11,12 In addition, the Prostate Cancer Prevention

Trial demonstrated that 24.4% of normal men in a

placebo group were eventually diagnosed with pros-

tate cancer.13

Observation until evidence that the cancer is

aggressive enough to warrant therapy may be appro-

priate for some patients but is potentially associated

with a lower cure rate once treatment is initiated.

Many patients with potentially insignificant tumors

are interested in the concept of active surveillance

with delayed intervention. Although attractive, this

approach is only feasible if we are able to clearly

identify patients when their disease is changing. The

challenge remains to accurately identify those men

with an aggressive, localized prostate cancer, which

has the potential to impact survival if left untreated,

while sparing or delaying treatment to avoid the

morbidity of a treatment that may not change the

natural history of the disease.

Active surveillance (AS) studies suggest that the

risk of disease progression increases over time, a pat-

tern that is different from the risk of disease progres-

sion or recurrence after definitive therapy, which

diminishes over time.14,15 Therefore, patients on AS

must accept frequent and regular evaluations of the

status of their cancer for as long as they remain

potential candidates for definitive therapy. Of the

various parameters monitored in these men, patho-

logic findings on prostate biopsy remain the most

objective measures of the evolution of their cancer.

Pathologic features such as grade and tumor volume

are important to monitor because they play a major

role in treatment decision-making of patients en-

rolled in AS. We reviewed the experience of our AS

cohort focusing on men with at least 1 prostatic

rebiopsy to better understand the prognostic signifi-

cance of the various clinical and pathologic diagnos-

tic characteristics and how they can help predict

patient outcome.

MATERIALS AND METHODSA cohort of 186 patients diagnosed between 1987

and 2006 with an adenocarcinoma of the prostate

with favorable pathologic and biochemical parame-

ters or those refusing definitive treatment were man-

aged with AS. The reasons for AS included patient

choice, limited life expectancy because of advanced

age or poor medical condition, and presumed insig-

nificant prostate cancer. Patients were followed at

3-month to 6-month intervals with serial serum PSA

levels and digital rectal examinations (DRE). PSAs

were performed with different assays during the ob-

servation period. Patients were offered transrectal

ultrasound (TRUS)-guided biopsy annually or if there

was a change on DRE or in the PSA value. Patients

were tracked prospectively in a disease management

database. All data were reviewed and analyzed retro-

spectively. Of the 186 patients under AS, 92 had at

least 1 repeat prostatic biopsy and constitute the

cohort of patients studied.

Clinical disease progression was defined as

increased T classification to �cT2b. Pathologic pro-

gression was defined by finding any of 1 of the follow-

ing pathologic features on repeat biopsy (provided

such findings were not present at the time of diagnos-

tic biopsy): 1) �3 positive cores, 2) >50% cancer in at

least 1 core, and 3) a predominant Gleason pattern of

4 noted on repeat biopsy.

All biopsies were retrospectively reviewed by 1 of

2 genitourinary pathologists (K.S. and L.R.B.). The

decision to initiate treatment was based on evidence

of pathologic disease progression on repeat biopsy,

biochemical disease progression, or patient prefer-

ence.

A PSA doubling time (PSADT) was calculated by

linear regression analysis.16 Progression-free survival

estimates were calculated using the Kaplan-Meier

method and comparative evaluations were performed

using the log-rank test. Univariate and multivariate

analysis for multiple variables were performed using

Cox regression analysis. The median value of each

variable was used as a cutoff except PSADT, in which

we used the tertile as a cutoff. All statistical analysis

were performed using Stata software (version 9.2;

StataCorp, College Station, Tex)

RESULTSThe median age at diagnosis was 67 years (range,

49–78 years). Of the 92 patients who were rebiopsied,

81 (88%) had a PSA � 10 ng/mL and 90 (98%) had

clinical �cT2a disease at the time of diagnosis. The

clinical and pathologic characteristics at diagnosis

are summarized in Table 1. The mean and median

follow-up was 79 months and 76 months, respec-

tively (range, 20–169 months). In our cohort, 42

patients, 25 patients, 13 patients, 10 patients, and 2

patients had 1, 2, 3, 4, and 5 repeat TRUS-guided

biopsies, respectively. Prostatic biopsies were per-

formed by different urologists within our division.

The mean and median numbers of biopsy cores were

7 and 8, respectively (range, 6-16 cores). Given our

long follow-up, several patients underwent an initial

Repeated Prostatic Biopsy/Al Otaibi et al. 287

sextant biopsy because it was the standard at the

time. Repeat biopsies were performed using a stand-

ard biopsy template.

At the time of this analysis, 34 patients (36%)

had either pathologic or clinical disease progression

(Fig. 1A) (Table 2). The first repeat biopsy was posi-

tive for cancer in 48 patients (52%) and negative in

44 patients (48%). Of the 48 patients with a positive

first repeat biopsy, 23 (48%) eventually demonstrated

either clinical or pathologic disease progression with

a mean and median time to disease progression of

16 months and 19 months, respectively. Only 11 of

the 44 patients (25%) with a negative first repeat

biopsy eventually demonstrated disease progression,

with a mean and median time to disease progression

of 19 months and 40 months, respectively. Of the 44

patients with negative first repeat biopsy, 13 patients

went on to have a second negative repeat prostatic

biopsy and 5 patients had �3 consecutive negative

repeat prostatic biopsies, and 4 patients and 0

patients, respectively, demonstrated clinical or patho-

logic disease progression.

The 5-year actuarial progression-free survival

probability was 82% for patients with a negative first

rebiopsy compared with 50% for those with a posi-

tive first rebiopsy (P 5 .02) (Fig. 1B).

In our cohort, 42 patients had a persistent posi-

tive repeated biopsy and 32 patients had a persistent

negative repeated biopsy. Clinical and pathologic

characteristics of the 2 groups at the time of diagno-

sis are illustrated in Table 3. The median PSADT in

patients with a persistently negative repeat prostatic

biopsy was 154 months and was 64 months in

patients with a positive repeat biopsy (P 5 .02).

Table 4 illustrates the multiple clinical and path-

ologic variables evaluated in a logistic regression

model to assess their ability to predict disease pro-

gression. The first repeated biopsy, the highest

percentage of cancer in any core at the time of diag-

nosis, Gleason score at diagnosis, PSA at diagnosis,

and the number of positive cores at diagnosis were

found to be predictive of disease progression on uni-

variate analysis (P � .02). On multivariate analysis, a

TABLE 1Clinical and Pathologic Features of the 92 Patients atthe Time of Diagnosis

Age, y

Mean 66 � 6

Median (range) 67 (49–78)

PSA, ng/mL

<4 21 (23%)

4.1-10 60 (65%)

10.1-20 9 (10%)

>20 2 (2%)

c-Stage

T1a 2 (2%)

T1c 64 (70%)

T2a 24 (26%)

T2b 2 (2%)

Gleason score

�6 71 (77%)

314 16 (18%)

413 3 (3%)

�8 2 (2%)

PSA indicates prostate-specific antigen.

FIGURE 1. (A) Overall probability of remaining free of disease progressionin all 92 patients. (B) Probability of remaining free of disease progression

stratified by the result of the first rebiopsy.

TABLE 2Number of Patients Who Developed Disease Progression in EachProgression Criterion

Progression criterion No. %

�cT2b 9 26

>50% cancer 13 38

Predominant grade 4 5 15

�3 positive cores 22 65

288 CANCER July 15, 2008 / Volume 113 / Number 2

PSADT � 67 months remained the only significant

predictor of disease progression.

Of the 92 men who were rebiopsied, 29 (31%)

ultimately received definitive treatment. The median

time to treatment was 44 months. Of these 29

patients, 10 patients (34.5%) were treated by radical

prostatectomy (RP), 9 patients (31%) were treated

with radiotherapy alone, 6 patients (21%) were trea-

ted with androgen ablation alone, and 4 patients

(14%) were treated with a combination of radiother-

apy and androgen ablation. The decision to treat was

attributed to local pathologic disease progression in

27 patients (93%) and patient preference in 2

patients (7%).

Of the 10 patients who underwent RP, all but 1

had organ-confined disease. Table 5 shows the clini-

cal and pathologic features of these patients.

Of the 13 patients who were treated by radiother-

apy, 11 were treated with external beam radiotherapy

and 2 were treated with brachytherapy (1 with per-

manent seed implant and the other with high-dose-

rate brachytherapy).

Of the 29 patients treated, 4 (13%) failed their

first-line treatment at a median post-treatment

follow-up of 48 months (Table 6). Of the 92 patients,

2 (2.2%) developed bone metastasis. No patients died

of prostate cancer; 2 patients died of other causes.

DISCUSSIONBetween 30% and 50% of patients with favorable,

localized prostate cancer remain free of progression

at 10 years on AS. Therefore, AS with definitive treat-

ment in those patients with disease progression may

be an attractive alternative to initial curative treat-

ment. Because the PSADT has been estimated to be

2 to 4 years, the median follow-up of 76 months,

which to our knowledge is the longest follow-up of

an AS series reported in the literature, represents 1 of

the strengths of the current study. For men on AS,

several factors have been investigated in an effort to

improve our ability to predict disease progression.

Diagnostic PSA values, including free and total levels,

were examined by several investigators including

ourselves and were not found to be helpful in the

identification of men who require therapy.16–23 Con-

versely, PSADT has been shown to be a predictor of

disease progression. Choo et al.18 suggested that the

definition of disease progression for men on AS

include a PSADT of <2 years on the basis of at least

3 separate PSA measurements during a minimum of

6 months. However, in their series using these crite-

ria, 6 of 9 men who underwent RP had extraprostatic

disease, suggesting that this PSADT threshold may

be too short to effectively identify patients at risk of

disease progression. In our cohort, only 5 patients

had a PSADT of <2 years and 3 of these patients

demonstrated pathologic disease progression. The

results of the current study demonstrated that a

PSADT of <67 months was associated with an

increased risk of pathologic disease progression.

Patel et al.24 did not find a correlation between

PSADT and disease progression in their series.

Our definition of pathologic disease progression

was based on criteria defining significant versus in-

significant prostate cancer. These criteria are being

used in ongoing clinical trials evaluating AS in

patients with prostate cancer. Pathologic disease pro-

gression was most often defined by an increase in tu-

mor volume, whereas only 5 patients (15%) were

considered to have disease progression as a result of

Gleason pattern upgrading to 4. Pathologic findings

of any cores involved with >20% of cancer at the

time of diagnosis or �2 cores positive for cancer at

the time of diagnosis were associated with an

increased risk of disease progression. The results of

the current study demonstrated that the absence of

cancer on repeated core needle biopsy early after

initial diagnosis identified those patients who were

TABLE 3Clinical and Pathologic Features at the Time of Diagnosis of thePatients With Persistently Positive and Patients With PersistentlyNegative Repeated Biopsy Results

Persistently Crude

Negative

(N532)

Positive

(N542) OR (95%CI) [P]*

Clinical stage

�T1c 20 (63%) 30 (71%)

T2a 12 (37%) 10 (24%) 0.6 (0.2–1.5) [03]

�T2b 2 (5%)

PSA, ng/mL

�4 11 (35%) 5 (12%)

>4 to �10 19 (59%) 30 (71%) 3.5 (1.04–11.6) [.043]

>10 to �20 2 (7%) 4 (10%) 4.4 (0.6–32.5) [.15]

>20 3 (7%)

Positive cores

1 28 (87%) 19 (45%)

�2 4 (13%) 23 (55%) 8.5 (2.5–28.4) [.001]

Median % of cancer y 6% 20%

Gleason score

�6 28 (88%) 28 (67%)

314 3 (9%) 12 (26%) 4.0 (1.0–15.7) [.04]

413 1 (3%) 2 (7%) 2.0 (0.2–23.3) [.58]

�8

OR indicates odds ratios; 95% CI, 95% confidence interval; PSA, prostate-specific antigen.

* Odd ratios were derived from logistic regression analysis.y The median of the core with the highest percentage of cancer.

Repeated Prostatic Biopsy/Al Otaibi et al. 289

less likely to develop disease progression. Patel

et al.24 and Carter et al.25 reported a similar associa-

tion between the results of first repeated biopsy and

the risk of disease progression. However, these stu-

dies were limited by their limited follow-up periods

of 44 months and 25 months, respectively. Surpris-

ingly, 4 (30%) of the 13 patients who had 2 consecu-

tive negative repeated biopsies after diagnosis

ultimately demonstrated disease progression on sub-

sequent biopsies and their median time to progres-

sion was 60 months. This reinforces the need to

maintain close follow-up and to continue to repeat

biopsy in patients on AS as long as they remain can-

didates for definitive therapy. In our cohort, men

who continued to have negative biopsies were unli-

kely to develop disease progress. Meanwhile, >50%

of the patients with cancer on repeat biopsy will de-

velop disease progression within 5 years. Therefore,

TABLE 4Incidence Rate and 95% CIs of Disease Progression Stratified by Covariate Variables as Well as Cox Regression Model to Assess WhetherThose Variables Can Predict Disease Progression With the Probability of Disease Progression Over Time

No.No. ofevent

Incident rate*(95% CI)

Cox regression model to predictdisease progression

Probability of disease progressionyCrude model Adjusted model

HR (95%CI) [P] HR (95%CI) [P] 12 months 24 months 60 months

Total 92 34 6.6 (4.7–9.2) 8.7 (4.5–16.6) 23.4 (15.9–33.6) 35.8 (26.3–47.3)

Median age at diagnosis, y

<67 37 15 5.9 (3.6–9.8) 8.1 (2.7–23.1) 31.0 (18.4–48.9) 33.9 (20.8–52.0)

�67 55 19 7.3 (4.6–11.4) 1 (0.5–2.0) [1.0] 9.1 (3.9–20.5) 18.5 (10.4–31.7) 38.5 (25.5–54.7)

First rebiopsy

Negative 44 11 3.9 (2.1–7.0) 9.1 (3.5–22.4) 13.8 (6.4–28.1) 19.3 (10.1–35.0)

Positive 48 23 10.0 (6.6–15) 2.5 (1.2–5.3) [.02] 2.0 (0.7–5.0) [.3] 8.3 (3.2–20.7) 32.16 (20.8–47.6) 50.7 (36.6–66.6)

T classification at diagnosis

�T1c 64 23 6.6 (4.4–9.9) 10.9 (5.4–21.6) 27.3 (17.9–40.2 35.7 (24.7–49.7)

>T1c 26 11 7.6 (4.2–13.7) 1.2 (0.6–2.4) [.7] 3.9 (0.5–24.3) 15.9 (6.3–37.0) 38.0 (21.7–60.7)

PSA doubling time, mo{

�67 29 17 14.9 (9.3–24.0) 3.4 (1.4–8.4) [.007] 3.0 (1.2–7.8) [.02] 10.3 (3.5–28.7) 35.7 (21.0–56.2) 58.7 (39.8–78.5)

>67 to �196 29 7 3.4 (1.6–7.2) 10.3 (3.5–28.7) 10.3 (3.5–28.7) 19.3 (8.4–40.7)

>196 30 8 4.3 (2.1–8.6) 1.2 (0.4–3.4) [.7] 6.7 (1.7–24.1) 20.4 (9.7–39.9) 28.4 (15.2–49.1)

Total core at diagnosis

�6 61 25 7.1 (4.8–10.5) 9.8 (4.54–20.6) 23.5 (14.7–36.5) 39.0 (27.6–53.2)

>6 31 9 5.5 (2.8–10.5) 0.7 (0.3–1.5) [.4] 6.5 (1.7–23.4) 23.2 (11.8–42.7) 27.8 (14.8–48.3)

% of core at diagnosis{

�20 49 12 3.9 (2.2–6.8) 4.1 (1.0–15.3) 16.8 (12.3–37.0) 21.8 (12.3–37.0)

>20 23 12 13.6 (7.7–23.9) 3.2 (1.4–7.2) [.006] 2.3 (0.8–6.2) [.10] 13.0 (4.4–35.2) 35.9 (19.8–81.6) 59.3 (38.0–82.0)

Prostate volume at diagnosis{

�40 34 13 6.3 (3.7–10.9) 11.8 (4.6–28.4) 20.8 (10.5–38.8) 32.0 (18.4–51.5)

>40 45 15 6 (3.6–9.9) 0.9 (0.4–1.9) [.8] 6.7 (2.2–19.3) 22.9 (13.0–38.4) 34.2 (21.6–51.1)

Gleason score at diagnosis

�6 69 20 4.8 (3.1–7.4) 7.3 (3.1–16.5) 22.1 (14.0–34.0) 25.6 (16.7–38.0)

>6 23 14 14.3 (8.5–24.2) 2.7 (1.4–5.5) [.04] 1.8 (0.8–4.0) [.15] 13.0 (4.4–35.2) 27.5 (13.4–51.4) 66.0 (45.0–85.6)

PSA at diagnosis, ng/mL

�10 77 24 5.3 (3.6–7.9) 5.2 (2.0–13.3) 21.6 (13.8–32.8) 30.2 (20.7–43.0)

>10 15 10 16.1 (8.7–30.0) 2.7 (1.4–5.8) [.008] 1.9 (0.8–4.8) [.16] 26.7 (11.0–56.4) 33.3 (15.4–62.5) 63.0 (39.2–86.2)

No. of rebiopsies performed

1 45 16 7.6 (4.7–12.5) 4.4 (1.1–16.6) 23.8 (13.5–39.7) 38.4 (25.0–56.0)

�2 47 18 5.9 (3.7–9.3) 0.9 (0.4–1.7) [.7] 12.8 (6.0–26.2) 23.4 (13.7–38.3) 33.1 (21.4–49.0)

Core at diagnosis

�1 62 18 4.7 (3.0–7.5) 8.1 (3.4–18.3) 18.1 (10.5–30.4) 26.5 (16.8–40.3)

>1 30 16 12.0 (7.3–19.5) 2.3 (1.2–4.7) [.02] 1.4 (0.5–3.9) [.48] 10.0 (3.3–27.9) 34.2 (20.1–54.3) 54.6 (37.1–74.0)

95% CI indicates 95% confidence interval; HR, hazards ratio; PSA, prostate-specific antigen.

* The progression incident rate is equal to the number of events per 1000 man-months.y The percentage probability of subjects developing disease progression at the end of the interval period (12 months, 24 months, and 60 months) derived by life table analysis (probability multiplied by 100).{ Does not sum to total because of missing values.

290 CANCER July 15, 2008 / Volume 113 / Number 2

we strongly recommend considering treatment in

men on AS who demonstrate cancer on repeat bi-

opsy. When pathologic disease progression was

observed on follow-up rebiopsy, it tended to occur

within the first 2 years after diagnosis in the majority

of cases. This occurred regardless of the result of the

first rebiopsy. An intensive biopsy protocol should be

pursued for men on AS during the first 2 years after

diagnosis. Of the patients treated with RP, only 1

(10%) had extracapsular extension, suggesting that a

strict surveillance protocol with serial DRE and

repeat prostatic biopsy allows for prompt and effec-

tive intervention in AS patients, whereas little or no

impact on curability of the disease is observed. De-

spite previous reports, we did not observe a signifi-

cant discrepancy between the TRUS biopsy and the

RP Gleason score. This may be a result of less sam-

pling error given the multiple TRUS biopsies before

surgery (median, 3 TRUS biopsies).

ConclusionsA strict annual rebiopsy strategy for the first 2 years

after diagnosis helps to identify those patients with

prostate cancer who are more likely to developed

disease progression on AS and appears to allow clini-

cians the opportunity to offer appropriate definitive

treatment without compromising cancer cure.

Patients with 2 consecutive negative repeated biop-

sies should continue to undergo repeat biopsy every

2 to 3 years. We encourage further study of rebiopsy

strategies and the continued follow-up of men on AS

to validate these findings.

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TABLE 5Clinical and Pathologic Features and Follow-up of Patients Treated by Radical Prostatectomy

Time totreatment, mo PSA at RP

Stage Gleason score

Surgical marginsPostoperativefollow-up, mo StatusClinical Pathologic Biopsy RP

1 17 7.3 T1c T2b 313 314 Negative 11 NED

2 27 7.1 T1c T2c 314 314 Negative 9 NED

3 16 5.0 T2a T2c 314 314 Negative 72 NED

4 84 6.1 T1c T2a 313 313 Negative 71 AWD

5 16 8.9 T1c T0* 414 Negative 108 NED

6 17 8.0 T1c T2a 314 313 Negative 72 NED

7 78 7.2 T2a T2a 313 313 Negative 48 NED

8 59 6.1 T1c T2a 313 313 Negative 18 NED

9 12 10.3 T2a T2b 312 314 Negative 47 NED

10 76 6.7 T1c T3a 314 314 Positive 44 AWD

PSA indicates prostate-specific antigen; RP, radical prostatectomy; NED, no evidence of disease; AWD, alive with disease.

* This patient received a luteinizing hormone-releasing hormone agonist 3 months prior to surgery.

TABLE 6Patients Who Underwent Treatment Stratified by Treatment Modality

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Median time to treatment

(range), mo

Median post-therapy

follow-up (range), mo

Treatment

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RP (n 5 10) 21 (17–84) 47 (9–108) 2

Radiotherapy (n 5 9) 34 (9–39) 57 (7–102) 1

Radiotherapy plus hormonal therapy (n 5 4) 48 (36–76) 44 (12–48) 1

Hormonal therapy (n 5 6) 52 (18–84) 45 (9–89) 0

RP indicates radical prostatectomy.

Repeated Prostatic Biopsy/Al Otaibi et al. 291

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292 CANCER July 15, 2008 / Volume 113 / Number 2