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Does MRI Improve Accuracy of Biopsy in Prostate Cancer Screening?
Increasingly, urologists are using magnetic resonance imaging (MRI) to inform decisions about biopsy in men who undergo prostate-specific antigen (PSA) screening for prostate cancer. Presumably, biopsies targeted to MRI abnormalities — rather than systematic but nontargeted biopsies — could reduce overdiagnosis of clinically insignificant cancers.
This Swedish trial involved 18,000 men (age range, 50–60) who had PSA screening. The 1200 men with PSA levels ≥3 ng/mL underwent MRI and were randomized to two groups. In one group, only MRI-detected abnormalities (seen in ≈40% of participants) were biopsied. In the other group, men underwent both MRI-targeted and standard systematic 12-core biopsies. Key findings were as follows:
- With the overall study population as the denominator, clinically insignificant prostate cancer (i.e., Gleason score, 3+3) was diagnosed significantly less frequently in the MRI-targeted group than in the targeted-plus-systematic biopsy group (0.6% vs. 1.2%). In contrast, clinically significant lesions were found in about 0.9% and 1.1% of patients in the two groups, respectively (a statistically nonsignificant difference).
- With men whose PSA was >3.0 ng/mL as the denominator, significant and insignificant cancers were found in 14% and 8% of men, respectively, in the MRI-targeted group. In contrast, significant and insignificant cancers were found in 17% and 18% of men, respectively, in the targeted-plus-systematic biopsy group.
Targeting prostate biopsies only to MRI-detected lesions could reduce overdiagnosis of clinically insignificant lesions — while missing a small number of clinically significant cancers. However, whether MRI will be incorporated formally into PSA screening protocols remains to be seen. Meanwhile, it's unlikely that refining PSA screening in this manner will be enough to convince skeptics that the overall benefits of PSA screening outweigh the harms.
Hugosson J et al.
Title: Prostate cancer screening with PSA and MRI followed by targeted biopsy only.
Source: N Engl J Med 2022 Dec 8; [e-pub]. (Abstract/FREE Full Text)