Prostate Biopsy is Associated with an Increased Risk of Erectile Dysfunction

The effect of transrectal ultrasound-guided prostate biopsy on erectile function and lower urinary tract symptoms: a prospective study

Background

Prostate biopsy (PB) is the gold standard for verifying the diagnosis of prostate cancer in men with clinical symptoms. Transrectal ultrasound (TRUS)-guided PB is the most common method for diagnosis; however, it has a few adverse effects. Mild consequences like bleeding and pain are prevalent but temporary. Since the relationship between erectile dysfunction and lower urinary tract symptoms (LUTS) and TRUS-guided PB is inconsistent in the literature, we aimed to conduct a study on these two consequences on males within 1 month following TRUS-guided PB.

Methods

Patients with a PSA ≥ 4 ml/ng who were determined to undergoTRUS-guided PB were enrolled in this prospective study. Patients' urinary symptoms and erectile function were evaluated using the International Prostate Symptom Score (IPSS) and International Index of Erectile Function-5 (IIEF-5) questionnaires the day before and 1 month after PB. Also, using uroflowmetry, the patients' urinary peak flow rate (Qmax) was recorded. SPSS version 18 was used to compare and analyze variables.

Results

The mean age of the participants was 67.47 ± 9.38 years. Before the PB, the IIEF-5 score was 20.19 ± 7.24, and after the PB, it was 20.25 ± 7.24 (p = 0.865). The Qmax level rose from 7.35 ± 2.15 to 7.74 ± 2 ml/s (p = 0.07). After TRUS-guided PB, the average IPSS score reduced from 11.48 ± 9.93 to 9.88 ± 8.22 which was statistically significant (p < 0.001).

Conclusions

This study indicated that TRUS-guided PB had no negative impact on erectile function or LUTS in participants and may even relieve urinary symptoms to some extent. Overally, TRUS-guided PB appears to be a safe strategy for evaluating prostate cancer suspects.

Decision fatigue in low-value prostate cancer screening

BACKGROUND

Low-value prostate-specific antigen (PSA) testing is common yet contributes substantial waste and downstream patient harm. Decision fatigue may represent an actionable target to reduce low-value urologic care. The objective of this study was to determine whether low-value PSA testing patterns by outpatient clinicians are consistent with decision fatigue.

METHODS

Outpatient appointments for adult men without prostate cancer were identified at a large academic health system from 2011 through 2018. The authors assessed the association of appointment time with the likelihood of PSA testing, stratified by patient age and appropriateness of testing based on clinical guidelines. Appointments included those scheduled between 8:00 am and 4:59 pm, with noon omitted. Urologists were examined separately from other clinicians.

RESULTS

In 1,581,826 outpatient appointments identified, the median patient age was 54 years (interquartile range, 37-66 years), 1,256,152 participants (79.4%) were White, and 133,693 (8.5%) had family history of prostate cancer. PSA testing would have been appropriate in 36.8% of appointments. Clinicians ordered testing in 3.6% of appropriate appointments and in 1.8% of low-value appointments. Appropriate testing was most likely at 8:00 am (reference group). PSA testing declined through 11:00 am (odds ratio [OR], 0.57; 95% CI, 0.50-0.64) and remained depressed through 4:00 pm (P < .001). Low-value testing was overall less likely (P < .001) and followed a similar trend, declining steadily from 8:00 am (OR, 0.48; 95% CI, 0.42-0.56) through 4:00 pm (P < .001; OR, 0.23; 95% CI, 0.18-0.30). Testing patterns in urologists were noticeably different.

CONCLUSIONS

Among most clinicians, outpatient PSA testing behaviors appear to be consistent with decision fatigue. These findings establish decision fatigue as a promising, actionable target for reducing wasteful and low-value practices in routine urologic care.

LAY SUMMARY

Decision fatigue causes poorer choices to be made with repetitive decision making. This study used medical records to investigate whether decision fatigue influenced clinicians' likelihood of ordering a low-value screening test (prostate-specific antigen [PSA]) for prostate cancer. In more than 1.5 million outpatient appointments by adult men without prostate cancer, the chances of both appropriate and low-value PSA testing declined as the clinic day progressed, with a larger decline for appropriate testing. Testing patterns in urologists were different from those reported by other clinicians. The authors conclude that outpatient PSA testing behaviors appear to be consistent with decision fatigue among most clinicians, and interventions may reduce wasteful testing and downstream patient harms.

Factors associated with appropriate and low-value PSA testing

BACKGROUND

Prostate-specific antigen (PSA) testing for early detection of prostate cancer is low-value when it is not indicated by guidelines and the harms outweigh the benefits. In this retrospective cohort study, we identify provider and patient factors associated with PSA testing, particularly in situations where testing would be low-value.

METHODS

We used electronic health record data from 2011 to 2018 representing 1,738,021 health system encounters in the United States. Using logistic generalized estimating equation models, we examined patient factors (age, comorbid illness, family history, race and prior PSA results), provider factors (gender, specialty, graduation year and medical school rank), and overall time trends associated with PSA testing in low-value and appropriate settings.

RESULTS

Comorbid illness (odds ratio (OR) 0.0 for 3+ conditions vs none) and no prior PSA testing (OR 0.2) were associated with a lower likelihood of PSA testing in low-value situations, while family history of prostate cancer (OR 1.6) and high prior PSA test results (OR 2.2 for PSA > 6 vs 0-1) were associated with a greater likelihood. Men aged 55-65 years were at greatest risk for PSA testing in low-value situations. The provider factor associated with PSA testing in low-value situations was specialty, with urologists being most likely (OR 2.3 versus advanced practice providers). Internal medicine physicians were more likely to perform PSA testing during low-value situations (OR 1.3 versus advanced practice providers) but much more likely to order a PSA test where appropriate (OR 2.2). All PSA testing decreased since 2011.

CONCLUSION

We identified several patient and provider factors associated with PSA testing in low-value settings. Some aspects suggest attention to relevant factors for PSA testing in low-value settings (e.g. comorbid illness), while others may encourage PSA testing in low-value settings (e.g. family history). The greatest likelihood of PSA testing in low-value settings is among men within the age range most commonly recommended by guidelines.

What false-negative rates of non-invasive testing are active surveillance patients and uro-oncologists willing to accept in order to avoid prostate biopsy?

INTRODUCTION

Repeat prostate biopsies in active surveillance patients are associated with significant complications. Novel imaging and blood/urine-based non-invasive tests are being developed to better predict disease grade and volume progression. We conducted a theoretical study to determine what test performance characteristics and costs would a non-invasive test(s) require in order for patients and their physicians to comfortably avoid biopsy.

METHODS

Surveys were administered to two populations to determine an acceptable false-negative rate and cost for such test(s). Active surveillance patients were recruited at time of followup in clinic at Princess Margaret Cancer Centre. Physician members of the Society of Urological Oncology were targeted via an online survey. Participants were questioned about their demographics and other characteristics that might influence chosen error rates and cost.

RESULTS

136 patients and 670 physicians were surveyed, with 130 (95.6%) and 104 (15.5%) responses obtained, respectively. A vast majority of patients (90.6%) were comfortable with a non-invasive test(s) in place of biopsy, with 64.8% accepting a false-negative rate of 5-20%. Most physicians (93.3%) were comfortable with a non-invasive test, with 77.9% accepting a rate of 5-20%. Most patients and physicians felt that a cost of less than $1000 per administration would be reasonable.

CONCLUSIONS

Most patients/physicians are comfortable with a non-invasive test(s). Although a 5% error rate seems acceptable to many, a substantial subset feels that 99% or higher negative predictive value is required. Thus, a personalized approach with shared decision-making between patients and physicians is essential to optimize patient care in such situations.