Negative first follow-up prostate biopsy on active surveillance is associated with decreased risk of upgrading, suspicion of progression and converting to active treatment.

To determine the risk of disease progression and conversion to active treatment following a negative biopsy while on AS for PCa.
Men on the AS programme at a single tertiary hospital (London, UK) between 2003-2018 with confirmed low-intermediate risk PCa, Grade Group<3, clinical stage <T3, diagnostic PSA 30% positive cores, MRI Likert>3/T3 or PSA>20. Conversion to treatment included radical or hormonal treatment.
Among the 460 eligible patients, 23% had negative follow-up biopsy findings. Median follow-up was 62 months, with 1-2 repeat biopsies and 2 magnetic resonance imaging scans per patient during that period. Negative biopsy findings at first repeat biopsy were associated with decreased risk of converting to active treatment (HR: 0.18; 95%CI: 0.09-0.37, p<0.001), suspicion of disease progression (HR 0.56: 95%CI: 0.34-0.94, p=0.029) and upgrading (HR: 0.48; 95%CI: 0.23-0.99, p=0.047). Data are limited by fewer men with multiple follow-up biopsies.
Negative biopsy findings at the first scheduled follow-up biopsy among men on AS for PCa was strongly associated decreased risk of subsequent upgrading, clinical or radiological suspicion of disease progression and conversion to active treatment. A less intense surveillance protocol should be considered for this cohort of patients.

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