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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