In this issue of European Urology, Kasivisvanathan et al. present a meta-analysis of two randomised trials comparing prebiopsy MRI with targeted biopsy (TBx) alone versus standard transrectal ultrasound-guided biopsy (TRUS-Bx) in biopsy-naïve men at risk of prostate cancer. Their findings show that MRI with TBx detects 8% more clinically significant cancers and reduces low-grade cancer diagnoses by 12%. Additionally, about one-third of patients could avoid biopsy based on negative MRI findings. This high-level evidence suggests that future trials may no longer ethically justify randomising patients to TRUS-Bx alone. Looking back, the prostate cancer diagnostic landscape has evolved significantly – from the era before prostate specific antigen (PSA) testing to widespread TRUS-Bx use, which, while effective at detecting localised disease, led to issues of overdiagnosis and biopsy-related complications. The emergence of multiparametric MRI (mpMRI) has offered more precise detection and reduced unnecessary biopsies. Now mpMRI is commonly used in cases of elevated PSA, prior negative biopsies, and active surveillance. Although its utilisation rose from 0.5% in 2007 to 35% in 2022, broader adoption is needed. Current guidelines vary: the National Comprehensive Cancer Network (NCCN) recommends mpMRI “if available”, the American Urological Association (AUA) says it “may” be used, and the European Association of Urology (EAU) includes it among diagnostic tools without clear direction to avoid TRUS-Bx alone. Secondary biomarkers like the MyProstateScore 2.0 show promise, especially when MRI access is limited. The authors argue, and rightly so, that MRI with TBx should become the global diagnostic standard for biopsy-naïve patients. While access remains a challenge, such guidance could drive investment in MRI infrastructure. A remaining concern is the management of MRI-invisible disease, though emerging data suggest these are often less aggressive. Clarifying this will help define biopsy pathways and optimise diagnostic precision going forward.
