In this issue of European Urology, Al-Monajjed et al. report findings from the PROBASE trial, which evaluated prostate cancer (PC) detection in men aged 45–50 years with PSA ≥3ng/ml using both MRI-targeted biopsy (TBx) and systematic biopsy (SBx). Among 525 men undergoing biopsy, SBx detected 94% of clinically significant PC (csPC) compared with 74% for TBx (p<0.05). Importantly, SBx identified 26% of csPCs that TBx alone would have missed, although it also increased detection of low-grade disease (84% vs. 43%). These results highlight a crucial point: in younger men, omission of SBx risks missing a substantial number of csPC cases. While MRI-visible lesions often harbour aggressive disease, MRI-invisible tumours, captured only by SBx, may still behave malignantly. In PROBASE, 13 csPCs were found in men with PI-RADS 1–2 scores, underscoring the lower negative predictive value of MRI in this age group. Factors such as smaller prostate size, tumour location, and limited radiologic experience may further complicate interpretation. SBx also contributes to risk stratification. Systematic cores provide information on tumour heterogeneity and bilaterality, improving prognostic models and guiding treatment choices. Moreover, with the rise of focal therapy, accurate tumour mapping is essential. Relying on TBx alone risks missing satellite foci beyond MRI visibility, with potential consequences for oncological control. The main counter-argument to SBx is overdiagnosis, since more indolent tumours are detected. However, with modern active surveillance and biomarker-guided follow-up, many harms of over-detection can be mitigated. Thus, the issue lies less in whether cancers are detected, and more in how they are managed. Taken together, PROBASE reinforces that in younger men, SBx remains indispensable. While advances in imaging, targeting, and AI may eventually reduce reliance on systematic sampling, at present SBx provides essential diagnostic and prognostic value that TBx alone cannot replace.
The case against omitting systematic biopsy in younger men
Reviewed by Asif H Ansari
The case against omitting systematic biopsy in younger men: evidence from the PROBASE Trial.
