Serial biopsies, sexual and erectile function, active surveillance, and related issues

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!

5 Responses

  1. There is a different study that looked at men who’d had serial biopsies prior to RALP vs those who’d had only one biopsy. The authors conclude:

    “Men subject to multiple preoperative biopsies are more likely to become impotent postoperatively than those who undergo surgery after a single biopsy.This should be borne in mind when counseling men regarding repeat biopsy as part of an active surveillance strategy.”

  2. Dear Allen:

    Thanks for this feedback … and you are right, this is a very different study. Out of a cohort of 367 patients who were given a RALP, the authors selected out “only premorbidly potent low-risk cases that underwent nerve sparing” who had had a single (n = 50) or multiple (n = 23) diagnostic biopsies prior to their surgery. They then imply that after RALP it was only the number of biopsies prior to surgery that affected their potency post-surgery.

    I think many researchers would argue that their conclusion is not justified by the data available, since this study is based on a small number of patients and the patients’ potency levels after their surgery (potentially) have little or nothing to do with the potency levels pre-surgery among men on active surveillance.

  3. Dear Sitemaster,

    Dr. Catalona had made the comment on a Prostate Foundation blog that multiple biopsies could increase the difficulty level towards a successful nerve-sparing radical prostatectomy (RP). I suspect that scarring between the neurovascular bundle, fascia, and prostate must be the reason, as normally the bundle should simply “peel away” from the prostate. The aforementioned study seems to corroborate Dr. Catalona’s comment. However one imagines that the surgeon performing the RALP RP might have noted any such scarring issues. Although, now I must wonder if open surgery with direct tactile access to the bundle is the better option for nerve sparing as I expect such feedback does not exist for RALP.

  4. Terence:

    Lots of things are “possible”. The truth may be more difficult to elicit, and I am quite certain that (a) the skill levels of individual surgeons is a critical factor and (b) the individual physiology of the individual patient is very important.

  5. My experience with the TRUS-guided biopsy was mixed and did involve numbness of my left leg for about 3 weeks and random pain, such as good jolts from the prostate area. However, I must question the efficacy of 20-year-old TRUS biopsy equipment when the newer MRI equipment with three-dimensional enhancements provides diagnostic quality images. Women I know with breast cancer get an MRI-guided biopsy, so we should too. I question the use of older, invasive processes.

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