Do men aged 75 years and older need prostate biopsy?

Aim. To evaluate advisability and safety of prostate biopsy in men aged ≥75 years with asymptomatic prostate cancer (PCa).

Materials and methods. The retrospective study included data of 206 patients aged ≥75 years with asymptomatic verified PCa. Median age was 83.0 (76.0–97.0) years. Indications for biopsy were increased prostate-specific antigen (PSA) level ≥4 ng/mL (188 (91.3 %)), palpable tumor of the prostate (8 (3.9 %)) or lesions identified using magnetic resonance imaging (MRI) and suspected for PCa (10 (4.8 %)). Median baseline PSA level was 11.9 (1.8–103.0) ng/mL. All patients underwent prostate biopsy.

Results. Complications of prostate biopsy were registered in 3 (1.5 %) of 206 patients. Adenocarcinoma of the prostate was verified in all cases (ISUP (International Society of Urological Pathology) grade 4–5 in 50 (24.3 %) samples). сТ3–4 category was diagnosed in 49 (23.8 %), сN1 – in 12 (5.8 %), сМ0 – in 206 (100 %) cases. The groups of intermediate unfavorable, high and very high risks included 133 (64.6 %) patients. Patients aged ≥80 years compared to patients aged 75–79 years demonstrated significantly increased rates of ISUP grade 4–5 adenocarcinomas (26.8 % vs.14.3 %), Т3–4 categories (26.8 % vs.11.9 %), and PCa of intermediate unfavorable, high and very high risks (68.3 % vs. 50/0 %) (p <0.05 for all). Frequency of detection of PCa of intermediate unfavorable, high and very high risks was significantly higher for PSA ≥10 ng/mL (p <0.0001) and was 100 % for MRI-detected lesions of the prostate PI-RADS 5 (Prostate Imaging Reporting and Data System). In 15 (7.3 %) cases, delayed treatment was administered, in 92 (44.6 %) cases – radical treatment, in 99 (48.1 %) – immediate drug treatment. Median follow-up was 38.6 (1.4–234.2) months, 17 (8.3 %) of 206 patients died including 4 (1.9 %) patients due to PCa. No differences in survival were observed in the treatment groups.

Conclusion. Prostate biopsy in men aged ≥75 years is associated with low complication rate. The frequency of detection of aggressive PCa forms in men aged ≥75 years is high and increases with age. Probability of detection of aggressive PCa significantly increased for baseline PSA ≥10 ng/mL and MRI-visualized prostate lesions PI-RADS 5.

1. State of oncological care in Russia in 2022. Eds.: А.D. Kaprin, V.V. Starinskiy, A.O. Shakhzadova. Moscow: MNIOI im. P.A. Gertsena – filial FGBU “NMITS radiologii” Minzdrava Rossii, 2023. 239 p. (In Russ.).

2. Sung H., Ferlay J., Siegel R.L. et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021;71(3):209–49. DOI: 10.3322/caac.21660

3. Boukovala M., Spetsieris N., Efstathiou E. Systemic treatment of prostate cancer in elderly patients: current role and safety considerations of androgen-targeting strategies. Drugs Aging 2019;36(8):701–17. DOI: 10.1007/s40266-019-00677-6

4. Coll P.P., Korc-Grodzicki B., Ristau B.T. et al. Cancer prevention and screening for older adults: part 2. Interventions to prevent and screen for breast, prostate, cervical, ovarian, and endometrial cancer. J Am Geriatr Soc 2020;68(11):2684–91. DOI: 10.1111/jgs.16794

5. Charlson M.E., Pompei P., Ales K.L., MacKenzie C.R. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40(5):373–83. DOI: 10.1016/0021-9681(87)90171-8

6. AUA guideline for prostate cancer. Available at: https://uroweb.org/guideline/prostate-cancer

7. Van Poppel H., Roobol M.J., Chapple C.R. et al. Prostate-specific antigen testing as part of a risk-adapted early detection strategy for prostate cancer: European Association of Urology Position and Recommendations for 2021. Eur Urol 2021;80(6):703–11. DOI: 10.1016/j.eururo.2021.07.024

8. Association JU. Screening guideline for prostate cancer. Japanese Urological Association. Medical View. Tokyo, Japan. 2018.

9. Krasnyi S.A., Tarend D.T., Semenov S.A. The results of prostate cancer screening and the problem of the hyperdiagnosis of the disease in the Republic of Belarus. Onkourologiya = Cancer Urology 2016;12(1):58–62. (In Russ.). DOI: 10.17650/1726-9776-2016-12-1-58-62

10. Order of the Ministry of Health of Russia from 27.04.2021 No. 404H. Available at: https://normativ.kontur.ru/document?moduleId=1&documentId=455086 (In Russ.).

11. Delongchamps N.B., Wang C.Y., Chandan V. et al. Pathological characteristics of prostate cancer in elderly men. J Urol 2009;182(3):927–30. DOI: 10.1016/j.juro.2009.05.018

12. Mistry S., Mayer W., Khavari R. et al. Who’s too old to screen? Prostate cancer in elderly men. Can Urol Assoc J 2009;3(3):205–10. DOI: 10.5489/cuaj.1071

13. Akman R.Y., Koseoglu H., Oguzulgen A.I. et al. Prostate biopsy in the elderly: histologic findings and treatment necessity. Asian Pac J Cancer Prev APJCP 2014;15(20):8937–9. DOI: 10.7314/apjcp.2014.15.20.8937

14. Huynh-Le M.P., Myklebust T.Å., Feng C.H. et al. Age dependence of modern clinical risk groups for localized prostate cancer-A population-based study. Cancer 2020;126(8):1691–9. DOI: 10.1002/cncr.32702

15. NCCN guideline for prostate cancer. Available at: https://www.nccn.org/home

16. Zhang Y., Zeng N., Zhang F. et al. How to make clinical decisions to avoid unnecessary prostate screening in biopsy-naïve men with PIRADs v2 score ≥3? Int J Clin Oncol 2020;25(1):175–86. DOI: 10.1007/s10147-019-01524-9

17. Liu C., Liu S.L., Wang Z.X. et al. Using the prostate imaging reporting and data system version 2 (PI-RIDS v2) to detect prostate cancer can prevent unnecessary biopsies and invasive treatment. Asian J Androl 2018;20(5):459–64. DOI: 10.4103/aja.aja_19_18

18. Baruah S.K., Das N., Baruah S.J. et al. Combining prostate-specific antigen parameters with prostate imaging reporting and data system score version 2.0 to improve its diagnostic accuracy. World J Oncol 2019;10(6):218–25. DOI: 10.14740/wjon1230

19. Loeb S., Vellekoop A., Ahmed H.U. et al. Systematic review of complications of prostate biopsy. Eur Urol 2013;64(6):876–92. DOI: 10.1016/j.eururo.2013.05.049

20. Gershman B., Van Houten H.K., Herrin J. et al. Impact of prostatespecific antigen (PSA) screening trials and revised PSA screening guidelines on rates of prostate biopsy and postbiopsy complications. Eur Urol 2017;71(1):55–65. DOI: 10.1016/j.eururo.2016.03.015

21. Zaytoun O.M., Anil T., Moussa A.S. et al. Morbidity of prostate biopsy after simplified versus complex preparation protocols: assessment of risk factors. Urology 2011;77(4):910–4. DOI: 10.1016/j.urology.2010.12.033

22. Raaijmakers R., Kirkels W.J., Roobol M.J. et al. Complication rates and risk factors of 5802 transrectal ultrasound-guided sextant biopsies of the prostate within a population-based screening program. Urology 2002;60(5):826–30. DOI: 10.1016/s0090-4295(02)01958-1