There has long been a concern that having multiple biopsies over a period of time (for whatever reason) could be associated with a risk for decline in sexual and erectile function. However, as far as we are aware, there has never been any compelling evidence to support or deny this concern.
The current guidelines on the management of very low- and low-risk, localized prostate cancer by active surveillance issued by the National Comprehensive Cancer Network (NCCN) recommend annual biopsies as a key element in the management strategy for men with low-risk, localized disease. Thus, many men are currently exposed to the probability of multiple, serial biopsies over a period of years, quite apart from the men who may need multiple biopsies before a diagnosis is established. At present, however, there are no really good data to establish whether annual biopsies (as opposed, for example, to annual MRIs or biopsies every other year) are a necessary element in the application of active surveillance to men with low-risk disease.
A new paper by Hilton et al. is at least helpful in regard to the risks associated with serial biopies and effects on sexual and erectile function over time.
Hilton and her colleagues report data on serial biopsies and sexual function between 2003 and 2010 from a cohort of men being managed on active surveillance at the prostate cancer clinic of the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco. Here are the core data that they report from their study:
- The cohort comprised 427 men on active surveillance.
- At time of initial diagnosis
- The average (median) age of the patients was 61 years.
- The average (median) PSA level was 5.3 ng/ml.
- 70 percent of the patients were clinical stage T1c.
- 93 percent of the patients had a Gleason score of < 7.
- These men were given 1,197 biopsies during the study period and completed 1,398 erectile function evaluations.
- Of the biopies that were followed by evaluations
- 40 percent were the patients’ first biopsies.
- 9 percent were the patients’ fifth to their ninth biopsies.
- At the time of first evaluation for sexual function
- 15 percent of patients stated that they were sexually inactive.
- 8 percent stated that they engaged in stimulation.
- 77 percent stated that they engaged in intercourse.
- The level of sexual activity changed between evaluations among > 20 percent of patients responding to questionnaires.
- Adjusted scores for erectile function
- Demonstrated no association with biopsy exposure
- Did demonstrate an association between level of sexual activity and greater levels of erectile function
- There was no apparent asociation between sexual activity and biopsy exposure.
Hilton and her colleagues conclude that (at least in this significant cohort of patients) there was no appearance of risk that erectile function or sexual activity were affected by the application of annual biopsies as a component of the active surveillance protocol being used at their institution.
The authors do also note — from a technical point of view — that the method they used to assess erectile function scores appeared to be superior to the use of the standard Sexual Health Inventory for Men scores because their method avoids biased assessment of erectile function.
This study does not resolve the issue of whether annual biopsies are actually necessary as a key component of active surveillance (as opposed to other methods of assessing risk for cancer progression). However, it certainly does help to alleviate the sense that annual serial biopsies increase risk for loss of or decline in erectile function and sexual activity — which for some strange reason seems to be very important to an awful lot of men!