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Background: Low-risk prostate cancer patients enrolled in active surveillance programs commonly undergo biopsies for examination of cancer progression. Biopsies are conducted as per a fixed and frequent schedule (e.g., annual biopsies). Since biopsies are burdensome, patients do not always comply with the schedule, which increases the risk of delayed detection of cancer progression. Objective: Our aim is to better balance the number of biopsies (burden) and the delay in detection of cancer progression (less is beneficial), by personalizing the decision of conducting biopsies. Data Sources: We use patient data of the world's largest active surveillance program (PRIAS). It enrolled 5270 patients, had 866 cancer progressions, and an average of nine prostate-specific antigen (PSA) and five digital rectal examination (DRE) measurements per patient. Methods: Using joint models for time-to-event and longitudinal data, we model the historical DRE and PSA measurements, and biopsy results of a patient at each follow-up visit. This results in a visit and patient-specific cumulative risk of cancer progression. If this risk is above a certain threshold, we schedule a biopsy. We compare this personalized approach with the currently practiced biopsy schedules via an extensive and realistic simulation study, based on a replica of the patients from the PRIAS program. Results: The personalized approach saved a median of six biopsies (median: 4, IQR: 2-5), compared to the annual schedule (median: 10, IQR: 3-10). However, the delay in detection of progression (years) is similar for the personalized (median: 0.7, IQR: 0.3-1.0) and the annual schedule (median: 0.5, IQR: 0.3-0.8). Conclusions: We conclude that personalized schedules provide substantially better balance in the number of biopsies per detected progression for men with low-risk prostate cancer.

Low risk prostate cancer patients enrolled in active surveillance (AS) programs commonly undergo biopsies on a frequent basis for examination of cancer progression. AS programs employ a fixed schedule of biopsies for all patients. Such fixed and frequent schedules, may schedule unnecessary biopsies for the patients. Since biopsies have an associated risk of complications, patients do not always comply with the schedule, which increases the risk of delayed detection of cancer progression. Motivated by the world's largest AS program, Prostate Cancer Research International Active Surveillance (PRIAS), in this paper we present personalized schedules for biopsies to counter these problems. Using joint models for time to event and longitudinal data, our methods combine information from historical prostate-specific antigen (PSA) levels and repeat biopsy results of a patient, to schedule the next biopsy. We also present methods to compare personalized schedules with existing biopsy schedules., Comment: 16 pages, 5 figures, 1 table. Supplementary materials available at https://goo.gl/jpPtL8